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)
What makes you anxious?
Work
Relationship
Health
Trauma & abuse
Grief
Child
News
Learning & School
Social interactions
Finances
Other
How much has your anxiety/worry interfered with your life, work, social activities, family, etc. during the last 2 weeks?
Never
Sometimes (1 - 4 times)
Often (5 - 10 times)
Regularly (over 10 times)
Over the past month, how often did you experienced a panic/anxiety attack?
Never
Sometimes (1 - 4 times)
Often (5 - 10 times)
Regularly (over 10 times)
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
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