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 allSeveral daysMore than half the daysNearly every day2. Not being able to stop or control worrying *Not at allSeveral daysMore than half the daysNearly every day3. Worrying too much about different things *Not at allSeveral daysMore than half the daysNearly every day4. Trouble relaxing *Not at allSeveral daysMore than half the daysNearly every day5. Being so restless that it's hard to sit still *Not at allSeveral daysMore than half the daysNearly every day6. Becoming easily annoyed or irritable *Not at allSeveral daysMore than half the daysNearly every day7. Feeling afraid as if something awful might happen *Not at allSeveral daysMore than half the daysNearly every dayIf you checked off any problem on this questionnaire, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? *Not difficult at allSomewhat difficultVery difficultExtremely difficultComment or MessageMessageSubmit
