Assess your current mental well-being.
Awful
Poor
Normal
Good
Very Good
Excellent
What makes you anxious?
Work
Relationship
Health
Trauma & abuse
Grief
Moving
News
Learning & school
Social interactions
Finances
Other
How often did you find it difficult to relax during the last 2 weeks?
Never
A couple of days
Most days
Every day
How often did you feel nervous, anxious, or on edge during the last 2 weeks?
Never
Sometimes (1 - 4 times)
Often (5 - 10 times)
Regularly (over 10 times)
Over the past 2 weeks, how much has your anxiety/worry interfered with your life, work, social activities, family, etc.?
Never
Sometimes
Often
Regularly
What physical symptoms of anxiety have you felt?
Stomach pain, nausea, or digestive trouble
Headache
Rapid breathing or shortness of breath
Pounding heart or increased heart rate
Sweating
Trembling or shaking
Other
None
What else have you experienced in the last 2 weeks?
Inability to relax/feeling agitated
Weakness or feel fatigued
Hard to concentrate
Increased irritability
Insomnia or other sleep issues (e.g., waking up frequently)
Muscle tension or pain
Panic attacks
Other
None
How often did you feel down, depressed, or hopeless during the last 2 weeks?
Never
Sometimes
Often
Regularly
How often did you experienced a panic attack during the last 2 month?
Never
A couple of days
Most days
Every day
Do you speak with a therapist on a regular basis?
Yes, I regularly see a therapist.
No, I have never seen a therapist.
No, but I have used a therapist in the past.
What are your favorite stress relievers?
🤗 Talking to people
🧘♀ Meditation
🤸 Physical activities
🎨 Creativity
📔 Journaling
💆 Self-care & spa
😢 Crying
🍿 Watching something
🎧 Listening to music
🚶♀️Walking
💭 Other
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