Anxiety Screening Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstMiddleLastDate of Birth: *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date: *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Over the last two weeks, how often have you been bothered by the following problems? Feeling nervous, anxious, or on edge *(0) Not at all(1) Several days(2) More than half the days(3) Nearly every dayNot being able to stop or control worrying *(0) Not at all(1) Several days(2) More than half the days(3) Nearly every dayWorrying too much about different things *(0) Not at all(1) Several days(2) More than half the days(3) Nearly every dayTrouble relaxing *(0) Not at all(1) Several days(2) More than half the days(3) Nearly every dayBeing so restless that it is hard to sit still *(0) Not at all(1) Several days(2) More than half the days(3) Nearly every dayBecoming easily annoyed or irritable *(0) Not at all(1) Several days(2) More than half the days(3) Nearly every dayFeeling afraid, as if something awful might happen *(0) Not at all(1) Several days(2) More than half the days(3) Nearly every dayTOTALS: How many times did you choose "Not at all" ? TOTAL:: 0 How many times did you choose "Several days" ? TOTAL:: 0 How many times did you choose "More than half the days" ? TOTAL:: 0 How many times did you choose "Nearly every day" ? TOTAL:: 0 Overall Score: *Add the previous four totals together to get your overall scoreDifficulties? If you checked any problems, how difficult have they made it for you to do your work, take care of things at home, or get along with other people? *Not difficult at allSomewhat difficultVery difficultExtremely difficult Scoring GAD-7 Anxiety Severity This is calculated by assigning scores of 0, 1, 2, and 3 to the response categories, respectively, of "not at all," "several days," "more than half the days," and "nearly every day." GAD-7 total score for the seven items ranges from 0 to 21.Results: Results: * 0-4: minimal anxiety 5-9: mild anxiety 10-14: moderate anxiety 15-21: severe anxiety Source: Primary Care Evaluation of Mental Disorders Patient Health Questionnaire (PRIME-MD-PHQ). The PHQ was developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke, and colleagues. For research information, contact Dr. Spitzer at ris8(columbia.edu. PRIME-MD® is a trademark of Pfizer Inc. Copyright© 1999 Pfizer Inc. All rights reserved. Reproduced with permissionSubmit
