GAD 7 Questionnaire

GAD-7 QUESTIONNAIRE

Please complete and submit copies as requested. Each close member of the family participating should complete their own form: i.e. Mum & Dad PLUS Parents should complete one copy on behalf of each child on the program (if they don't submit their own).
Name*

First NameLast Name
Email*
example@example.com
Age*
Notes

This GAD-7 screening tool can help you find out if you or your child may have an anxiety disorder.
It calculates how many common symptoms you have and — based on your answers — suggests where you might be on a scale, from mild to severe anxiety.

GAD-7 stands for "generalized anxiety disorder" and the 7 questions in the tool.
Scoring

GAD-7 Anxiety Severity.

This is calculated by assigning scores of 0, 1, 2, and 3, to the response categories of “not at all,” “several days,” “more than half the days,” and “nearly every day,” respectively. GAD-7 total score for the seven items ranges from 0 to 21.

Scores represent:

0-5 mild, 6-10 moderate, 11-15 moderately severe anxiety, 15-21 severe anxiety.
Results

We ask all families to complete the GAD-7 Questionnaires twice : Firstly on enrolment, and secondly after completion of the 12 week program.

The scores and results are being co-ordinated by our in house Integraded Child Psychotherapist - who will confirm to you on receipt of the completed forms the individual scores at each stage for each participant.
Choose one of the 4 answers for each of the 7 questions below :

	Not At All	Several Days	More Than Half The Days	Nearly Everyday
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's hard to sit still ?
6. Becoming easily annoyed or irritable ?
7. Feeling afraid as if something awful might happen ?

Signature

Clear
From the 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 rls8@columbia.edu. PRIME-MD® is a trademark of Pfizer Inc. Copyright© 1999 Pfizer Inc. All rights reserved. Reproduced with permission.
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GAD-7 QUESTIONNAIRE