GAD 7 Anxiety

Patient's Name

First Name Last Name

Over the last two weeks, how often have you been bothered by the following problems?

	Not at all	Several days	More than half the days	Nearly every day
1. Feeling nervous, anxious, or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it is hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid as if something awful might happen

A. If you rated any of the questions as "not at all", please enter "0" here? Ex: 3x 0 = 0

B. If you rated any of the questions as "several days", please multiply the number of selections by 1 and enter the total here. Ex: 3 x 1 = 3

C. If you rated any of the questions as "more than half the days", please multiply the number of selections by 2 and enter the total here. Ex: 3 x 2 = 6

D. If you rated any of the questions as "nearly every day" please multiply the number of selections by 3 and enter the total here. Ex: 3 x 3 = 9

Please add the total of your answers in Section A through D and enter it here.

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 all	Somewhat difficult	Very difficult	Extremely difficult

My signature below attests that I or my Personal Representative completed this scale.

Patient or Personal Representative's Signature

Clear

Date

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 permission

GAD - 7 ANXIETY