Anxiety Questionnaire

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Are you experiencing symptoms of anxiety?

Are you experiencing symptoms of anxiety?

1
Over the past 2 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
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Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
2. Not being able to stop or control worrying
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
3. Worrying too much about different things
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Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
4. Trouble relaxing
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
5. Being so restless that it is hard to sit still
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Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
6. Becoming easily annoyed or irritable
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Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
7. Feeling afraid as if something awful might happen
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Row 6, Column 2
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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
Not at all
Row 0, Column 0
Several Days
Row 0, Column 1
More than half the days
Row 0, Column 2
Nearly every day
Row 0, Column 3
Not at all
Row 1, Column 0
Several Days
Row 1, Column 1
More than half the days
Row 1, Column 2
Nearly every day
Row 1, Column 3
Not at all
Row 2, Column 0
Several Days
Row 2, Column 1
More than half the days
Row 2, Column 2
Nearly every day
Row 2, Column 3
Not at all
Row 3, Column 0
Several Days
Row 3, Column 1
More than half the days
Row 3, Column 2
Nearly every day
Row 3, Column 3
Not at all
Row 4, Column 0
Several Days
Row 4, Column 1
More than half the days
Row 4, Column 2
Nearly every day
Row 4, Column 3
Not at all
Row 5, Column 0
Several Days
Row 5, Column 1
More than half the days
Row 5, Column 2
Nearly every day
Row 5, Column 3
Not at all
Row 6, Column 0
Several Days
Row 6, Column 1
More than half the days
Row 6, Column 2
Nearly every day
Row 6, Column 3
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2
Name* This field is required.
First Name
Last Name
3
Phone Number* This field is required.
Please enter a valid phone number.
4
Email* This field is required.
example@example.com
5
Score 0-5 Minimal 6-10 Mild 11-15 Moderate 16-21 Severe
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