Penn State Worry Questionnaire
Please take a moment to complete this questionnaire.
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1. What are the problems / symptoms you want to work on?
2. What situations or events trigger the problem?
3. How frequently do you experience the problem?





4. How distressing / intense are the symptoms?





5. How does this affect your work / social / personal life?
6. When you experience the problem, what negative thoughts do you have about yourself, other people or the situation?
7. When you experience the problem, how do you feel emotionally; what feelings do you have E.g. anxious, depressed, angry .
8. When you experience the problem, how do you feel physically; what sensations or physical feelings do you notice in your body?
9. When you experience the problem, what do you do or avoid doing?
10. What tends to make the problem worse?
11. What tends to make the problem better?
12. What do you believe are the causes of the problem; what made you vulnerable to the problem in the first instance?
13. Do you ever experience thoughts of harming yourself or ending your life?





14. Please provide details of any current/recent medication.
15. Please provide details of any substance use.
16. Please provide details of any current / recent therapy or counselling undertaken for this or any other problem.
17. Please provide details of any other current or past psychological / medical problems that you have experienced.
18. Please provide your GPs name and practice address.
19. Please provide a preferred telephone number and email address that we can contact you on.
20. Please provide your date of birth.