Cognitive Therapy of Anxiety Disorders

16 4

From Cognitive Therapy of Anxiety Disorders: Science and Practice by David A. Clark and Aaron T. Beck. Copyright
2010 by The Guilford Press. Permission to photocopy this appendix is granted to purchasers of this book for personal
use only (see copyright page for details).

aPPENDIX 5.3

Physical Sensation Self-Monitoring Form

Name: Date:

Directions: Please write down any situations or experiences that caused an increase in your anxiety.
Pay particular attention to whether you experienced any of the bodily sensations listed on this form
while you were in that situation. Use the rating scales beside each sensation to indicate how you
felt about the bodily reaction.

1. Briefly describe anxious situation:

Record level of anxiety in situation (0–100 scale):

Checklist of physical sensations experienced in situation:

Physical Sensation

Intensity of Physical Sensation

[Use 0–100 scale defined below]

anxiousness about

Physical Sensation

[Use 0–100 scale defined below]

Chest tightness

Elevated heart rate

Trembling, shaking

Difficulty breathing

Muscle tension

Nausea

Lightheaded, faint, dizzy

Weak, unsteady

Feeling warm, sweaty

Dry mouth

(cont.)