Please enable JavaScript in your browser to complete this form.Your Name and relationship to patient *Telehealth Appointment Provider *Patient Name *FirstLastDate of Birth *Email *1. Feeling nervous, anxious, or on edge *Not at all Several daysMore than half the daysNearly every day2. Not being able to stop or control worrying *Not at all Several daysMore than half the daysNearly every day3. Worrying too much about different things *Not at all Several daysMore than half the daysNearly every day4. Trouble relaxing *Not at all Several daysMore than half the daysNearly every day5. Being so restless that it's hard to sit still *Not at all Several daysMore than half the daysNearly every day6. Becoming easily annoyed or irritable *Not at all Several daysMore than half the daysNearly every day7. Feeling afraid as if something awful might happen *Not at all Several daysMore than half the daysNearly every dayComment or MessageEmail *Email *CommentSubmit
