Our Anxiety Check-In

not a diagnosis

First Name *

Last Name *

Email *

Phone

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Feeling nervous, anxious or on edge *

Not at all

Several Days

More than half the days

Nearly Every Day

Not being able to stop or control worrying *

Not at all

Several Days

More Than Half the Days

Nearly Every Day

Worrying too much about different things *

Not at all

Several Days

More than half the days

Nearly Every Day

Trouble relaxing *

Not at all

Several Days

More than half the days

Nearly Every Days

Being so restless that it is hard to sit still *

Not at all

Several Days

More than half the days

Nearly Every Day

Becoming easily annoyed or irritable *

Not at all

Several Days

More than half the days

Nearly Every Day

Feeling afraid as if something awful might happen *

Not at all

Several Days

More than half the days

Nearly Every Day

Score meaning

Score 0-4: Minimal Anxiety
Score 5-9: Mild Anxiety
Score 10-14: Moderate Anxiety
Score greater than 15: Severe Anxiety

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This is not a diagnosis*

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