Anxiety Severity QuestionnaireAnxiety Severity QuestionnaireMichael Frampton M.D., P.C.9120 Connecticut Drive, Suite AMerrillville, IN 46410First NameMiddle InitialLast NameSuffix (Sr, Jr, etc)Date / TimeOver the last two weeks, how often have you been bothered by the following problems? 1. Feeling nervous, anxious, or on edge? 0 - Not at all 1 - Several Days 2- More than half the days 3 - Nearly Every Day2. Not being able to stop or control worrying? 0 - Not at all 1 - Several Days 2- More than half the days 3 - Nearly Every Day3. Worrying too much about different things? 0 - Not at all 1 - Several Days 2- More than half the days 3 - Nearly Every Day4. Trouble relaxing? 0 - Not at all 1 - Several Days 2- More than half the days 3 - Nearly Every Day5. Being so restless it's hard to sit still? 0 - Not at all 1 - Several Days 2- More than half the days 3 - Nearly Every Day6. Becoming easily annoyed or irritable? 0 - Not at all 1 - Several Days 2- More than half the days 3 - Nearly Every Day7. Feeling afraid, as if something awful may happen? 0 - Not at all 1 - Several Days 2- More than half the days 3 - Nearly Every DayTotal Score:If you checked any problems, how difficult have they made it for you to do your work, take care of things at home, or get along with other people? Not difficult at all Somewhat difficult Very difficult Extremely difficultScoring GAD-7 Anxiety SeverityThis is calculated by assigning scores of 0, 1, 2, and 3 to the response categories, respectively, of “not at all,” “several days,” “more than half the days,” and “nearly every day.” GAD-7 total score for the seven items ranges from 0 to 21:0–4: minimal anxiety5–9: mild anxiety10–14: moderate anxiety15–21: severe anxietySource: Primary Care Evaluation of Mental Disorders Patient Health Questionnaire (PRIME-MD-PHQ). The PHQ was developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke, and colleagues. For research information, contact Dr. Spitzer at ris8@columbia.edu. PRIME-MD® is a trademark of Pfizer Inc. Copyright© 1999 Pfizer Inc. All rights reserved. Reproduced with permissionEmail Address:Retype Email Address:Submit Form
