GAD-7

Patient Name:

Today’s Date

Patient DOB:

Over the LAST 2 WEEKS, how often have you been bothered by the following problems?

1. Feeling Nervous, anxious or on edge

Not at All - 0 Several days - 1 More than half the days - 2 Nearly everyday - 3

2. Not being able to stop or control worrying

Not at All - 0 Several days - 1 More than half the days - 2 Nearly everyday - 3

3. Worrying too much about different things

Not at All - 0 Several days - 1 More than half the days - 2 Nearly everyday - 3

4. Trouble relaxing

Not at All - 0 Several days - 1 More than half the days - 2 Nearly everyday - 3

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

Not at All - 0 Several days - 1 More than half the days - 2 Nearly everyday - 3

6. Becoming easily annoyed or irritable

Not at All - 0 Several days - 1 More than half the days - 2 Nearly everyday - 3

7. Feeling afraid something awful might happen

Not at All - 0 Several days - 1 More than half the days - 2 Nearly everyday - 3

For Office coding: Total Score