Anxiety Free Treatment Screening

Name or Nickname (optional)

Email

Phone

Answer the following questions based on:

Over the last two weeks, how often have you been bothered by the following problems?

Feeling nervous, anxious, or on edge

0 (Not At All)

1 (Several Days)

2 (More than Half The Days

3 (Nearly Every Day)

Not being able to stop or control worrying

0 (Not At All)

1 (Several Days)

2 (More than Half The Days

3 (Nearly Every Day)

Worrying too much about different things

0 (Not At All)

1 (Several Days)

2 (More than Half The Days

3 (Nearly Every Day)

Trouble relaxing

0 (Not At All)

1 (Several Days)

2 (More than Half The Days

3 (Nearly Every Day)

Being so restless that it is hard to sit still

0 (Not At All)

1 (Several Days)

2 (More than Half The Days

3 (Nearly Every Day)

Becoming easily annoyed or irritable

0 (Not At All)

1 (Several Days)

2 (More than Half The Days

3 (Nearly Every Day)

Feeling afraid, as if something awful might happen

0 (Not At All)

1 (Several Days)

2 (More than Half The Days

3 (Nearly Every Day)

Total Score From Questions Above

If you checked any problems above, 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 All

Somewhat Difficult

Very Difficult

Extremely Difficult