Full Name
*
Email
*
Phone
Over the last 2 weeks, how often have you been feeling nervous, anxious, or on edge?
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Not at all
Several days
More than half the days
Nearly every day
Over the last 2 weeks, how often have you been unable to stop or control worrying?
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Not at all
Several days
More than half the days
Nearly every day
Over the last 2 weeks, how often have you worried too much about different things?
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Not at all
Several days
More than half the days
Nearly every day
Over the last 2 weeks, how often have you had trouble relaxing
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Not at all
Several Days
More than half the days
Nearly every day
Over the last 2 weeks, how often have you been so restless that it was hard to sit still?
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Not at all
Several Days
More than half the days
Nearly every day
Over the last 2 weeks, how often have you become easily annoyed or irritable?
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Not at all
Several Days
More than half the days
Nearly every day
Over the last 2 weeks, how often have you felt afraid as if something awful might happen?
*
Not at all
Several Days
More than half the days
Nearly every day
