Form

1. Feeling nervous, anxious, or on edge

Not at all

Less than 7 days

More than 7 days

Nearly every day

2. Not being able to stop or control worrying.

Not at all

Less than 7 days

More than 7 days

Nearly every day

3. Worrying too much about different things

Not at all

Less than 7 days

More than 7 days

Nearly every day

4. Having trouble relaxing

Not at all

Less than 7 days

More than 7 days

Nearly every day

5. Being so restless that it is hard to sit still

Not at all

Less than 7 days

More than 7 days

Nearly every day

6. Becoming easily annoyed or irritable.

Not at all

Less than 7 days

More than 7 days

Nearly every day

7. Feeling afraid as if something awful might happen

Not at all

Less than 7 days

More than 7 days

Nearly every day

8. In the last 4 weeks, have you had an anxiety attack ⎯ suddenly feeling fear or panic, accompanied by shortness of breath, sweating, palpitations ?

Yes

No

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