Name *

First Name

Last Name

1. Feeling nervous, anxious or on edge *

Over the last 2 weeks, how often have you been bothered by the above problem?

Not at all

Several days

More than half the days

Nearly every day

2. Not being able to stop or control worrying *

Over the last 2 weeks, how often have you been bothered by the above problem?

Not at all

Several days

More than half the days

Nearly every day

3. Worrying too much about different things *

Over the last 2 weeks, how often have you been bothered by the above problem?

Not at all

Several Days

More than half the days

Nearly every day

4. Trouble relaxing *

Over the last 2 weeks, how often have you been bothered by the above problem?

Not at all

Several days

More than half the days

Nearly every day

5. Being so restless that it is hard to sit still *

Over the last 2 weeks, how often have you been bothered by the above problem?

Not at all

Several days

More than half the days

Nearly every day

6. Becoming easily annoyed or irritable *

Over the last 2 weeks, how often have you been bothered by the above problem?

Not at all

Several days

More than half the days

Nearly every day

7. Feeling afraid as if something awful might happen *

Over the last 2 weeks, how often have you been bothered by the above problem?

Not at all

Several days

More than half the days

Nearly every day