GAD-7 Scale
Essex Pediatrics • 89 Main Street, Essex Junction, VT 05452 • (802) 879-6556
Patient Name
*
First Name
Last Name
Patient Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Today's Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
What brings you joy?
Who can you go to for help?
What are you good at?
What do you look forward to?
Over the last two weeks, how often have you been bothered by the following problems?
*
Rows
Not at all
(0)
Several days
(1)
More than half the days
(2)
Nearly every day
(3)
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 it's hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid as if something awful might happen
Total Score
If you checked off any problems, how difficult have these 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
Submit
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