Anxiety Self-Assessment Over the last 2 weeks, on how many days have you been bothered by any of the following problems? Name Question 1 Feeling nervous, anxious or on edge? Feeling nervous, anxious or on edge? Not at all Several days More than half the days Nearly every day Question 2 Not being able to stop or control worrying? Not being able to stop or control worrying? Not at all Several days More than half the days Nearly every day Question 3 Worrying Too Much about things? Worrying Too Much about things? Not at all Several days More than half the days Nearly every day Question 4 Trouble Relaxing? Trouble Relaxing? Not at all Several days More than half the days Nearly every day Question 5 Being so restless it's hard to be still? Being so restless it's hard to be still? Not at all Several days More than half the days Nearly every day Question 6 Being easily annoyed or irritable? Being easily annoyed or irritable? Not at all Several days More than half the days Nearly every day Question 7 Feeling afraid that something awful might happen? Feeling afraid that something awful might happen? Not at all Several days More than half the days Nearly every day First Name Last Name Phone Number Email Address
