Penfield Psychiatry
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Mental Health Assistant
Generalized Anxiety Disorder
Patient Name
*
First
Last
Today's Date
*
MM slash DD slash YYYY
Over the past 2 weeks, how often have you been bothered by any of the following problems?
Feeling nervous, anxious or on edge
*
0 - Not at all
1 - Several days
2 - More than half the days
3 - Nearly every day
Not being able to stop or control worrying
*
0 - Not at all
1 - Several days
2 - More than half the days
3 - Nearly every day
Worrying too much about different things
*
0 - Not at all
1 - Several days
2 - More than half the days
3 - Nearly every day
Trouble relaxing
*
0 - Not at all
1 - Several days
2 - More than half the days
3 - Nearly every day
Being so restless that it is hard to sit still
*
0 - Not at all
1 - Several days
2 - More than half the days
3 - Nearly every day
Becoming easily annoyed or irritable
*
0 - Not at all
1 - Several days
2 - More than half the days
3 - Nearly every day
Feeling afraid as if something awful might happen
*
0 - Not at all
1 - Several days
2 - More than half the days
3 - Nearly every day
Total Score
*
Clinician Notes
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