Over the past two weeks, to what extent have you been troubled by the following problems?
Feeling anxious, nervous, or on edge
Never
Some of the time
Most of the time
Nearly all of the time
Difficulty stopping or controlling your worry
Never
Some of the time
Most of the time
Nearly all of the time
Worrying too much about a lot of different things
Never
Some of the time
Most of the time
Nearly all of the time
Having difficulty relaxing
Never
Some of the time
Most of the time
Nearly all of the time
Severe restlessness, inability to sit still
Never
Some of the time
Most of the time
Nearly all of the time
Becoming easily irritable or annoyed at even minor things
Never
Some of the time
Most of the time
Nearly all of the time
Suffering from a feeling of fear, as if something bad is about to happen
Never
Some of the time
Most of the time
Nearly all of the time
Difficulty falling or staying asleep due to constant worry
Never
Some of the time
Most of the time
Nearly all of the time
Have you been treated with at least two (2) or more types of anti-anxiety medications with no significant symptom relief?
No, I have never been on anti-anxiety medication
I am currently prescribed one medication to treat anxiety
I am currently prescribed two or more medications to treat anxiety
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