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Anxiety Screening (GAD-7)
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Name
*
First
Last
Email
*
Phone
Date of Birth:
Over the last 2 weeks, how often have you been bothered by the following problems?
Feeling nervous, anxious or on edge
*
Select One
Not at all
Several days
More than half the days
Nearly every day
Not being able to stop or control worrying
*
Select One
Not at all
Several days
More than half the days
Nearly every day
Worrying too much about different things
*
Select One
Not at all
Several days
More than half the days
Nearly every day
Trouble relaxing
*
Select One
Not at all
Several days
More than half the days
Nearly every day
Being so restless that it’s hard to sit still
*
Select One
Not at all
Several days
More than half the days
Nearly every day
Becoming easily annoyed or irritable
*
Select One
Not at all
Several days
More than half the days
Nearly every day
Feeling afraid as if something awful might happen
*
Select One
Not at all
Several days
More than half the days
Nearly every day
Hidden able Birth:
Results
Results
Results of the assessment 1
Minimal
Results of the assessment 2
Mild
Results of the assessment 3
Moderate to Severe
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