Anxiety Assessment Rating Scale

Anxiety Assessment Rating Scale
Patient Name*

First NameLast Name
Today's Date*

MonthDayYear
Date of Visit
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Are you currently a patient/client at Impireum?*

YesNo
Anxiety Assessment Rating Scale - Over the last 2 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
PHQ-10 Calculation*
***Important: Follow-Up on Your Anxiety GAD-7 Assessment***

0–4: Normal

5–9: Mild

10–14: Moderate

15+: Severe

If Your Anxiety Rating score is 10 or higher, we recommend you speak with a professional mental health provider.

An Impireum representative will reach out to you or register as a new patient.

Or please promptly contact a mental health provider for support.
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