GAD-7 Questionnaire

GAD-7 Questionnaire

CONFIDENTIAL
Client Full Name*

First NameLast Name
Gender:*

MaleFemale
Client Email Address*
example@example.com
Which therapist are you scheduled with? *

I do not have a therapist at The Peacemaker CenterOther
Over the last two weeks, how often have you been bothered by the following problems?
1. Feeling nervous, anxious, or on edge*

Not at allSeveral daysMore than half the daysNearly every day
2. Not being able to stop or control worrying*

Not at allSeveral daysMore than half the daysNearly every day
3. Worrying too much about different things*

Not at allSeveral daysMore than half the daysNearly every day
4. Trouble relaxing*

Not at allSeveral daysMore than half the daysNearly every day
5. Being so restless that it is hard to sit still*

Not at allSeveral daysMore than half the daysNearly every day
6. Becoming easily annoyed or irritable*

Not at allSeveral daysMore than half the daysNearly every day
7. Feeling afraid, as if something awful might happen*

Not at allSeveral daysMore than half the daysNearly every day
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 allSomewhat difficultVery difficultExtremely difficult
Screening Score
Your responses are for screening purposes only. Press the Submit button below. We would love the opportunity to discuss your results with you. If you are not currently a client please complete our Appointment Request form at www.thepeacemakercenter.org.

SCREENING RESULTS:

0–4: minimal anxiety
5–9: mild anxiety
10–14: moderate anxiety
15–21: severe anxiety
Should be Empty: