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GENERALIZED ANXIETY DISORDER SCREEN
These questions refers to the past 6 MONTHS
1. Most days I feel very nervous.
Please select
YES
NO
2. Most days I cannot stop worrying.
Please select
YES
NO
3. Most days I worry about lots of things.
Please select
YES
NO
4. Most days my worry is hard to control.
Please select
YES
NO
5. I feel restless, keyed up or on edge.
Please select
YES
NO
6. I tired easily.
Please select
YES
NO
7. I have trouble concentrating.
Please select
YES
NO
8. I am easily annoyed or irritated.
Please select
YES
NO
9. My muscles are tense and tight.
Please select
YES
NO
10. I have trouble sleeping.
Please select
YES
NO
11. Did the things you noted above affect your daily life (home life, work, or leisure) or cause you a lot of distress?
Please select
YES
NO
12. Were the things you noted above bad enough that you thought about getting help for them?
Please select
YES
NO
5 or more 'YES' answers indicate anxiety. The more 'YES' answers you have,the more severe your anxiety.
Write in the number of 'YES' answers below.
Would you like Dr. Pinjala to contact you regarding these results?
Yes
No
Name
First
Last
Email
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