GAD-7

1. Feeling nervous, anxious or on edge *

• Not at all
• Several days
• More than half the days
• Nearly every day

2. Not being able to stop or control worrying *

• Not at all
• Several days
• More than half the days
• Nearly every day

3. Worrying too much about different things *

• Not at all
• Several days
• More than half the days
• Nearly every day

4. Trouble relaxing *

• Not at all
• Several days
• More than half the days
• Nearly every day

5. Being so restless that it is hard to sit still *

• Not at all
• Several days
• More than half the days
• Nearly every day

6. Becoming easily annoyed or irritable *

• Not at all
• Several days
• More than half the days
• Nearly every day

7. Feeling afraid as if something awful might happen *

• Not at all
• Several days
• More than half the days
• Nearly every day

_{IF YOU THINK YOU ARE EXPERIENCING A MEDICAL EMERGENCY, CALL YOUR MEDICAL PROVIDER OR 911 IMMEDIATELY.}

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Name *

Date of Birth *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

Provider Name

Provider Email

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