Anxiety GAD-7 Survey

Carencia Anxiety Survey (GAD-7)
PATIENT SAFETY AGREEMENT*

Carencia does not review your submissions right away. If you are having thoughts of hurting yourself or are worried about someone’s safety please call 911 or the national crisis hotline at 988 https://988lifeline.org
SURVEY DISCLAIMER*

This questionnaire should be used as a starting point. It is not a substitute for a full medical evaluation. Anxiety disorder is a complex illness, and an accurate, thorough diagnosis can only be made through a personal evaluation by your provider.
GAD-7 Anxiety Survey

Over the last two weeks, how often have you been bothered by the following problems?*

	Not at All	Several Days	More than Half the Days	Nearly Every Day
1. Feeling nervous, anxious, or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it is hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid, as if something awful might happen

Total 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 allSomewhat difficultVery difficultExtremely difficult
GAD-7 Anxiety scoring
This 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 anxiety
5–9: mild anxiety
10–14: moderate anxiety
15–21: severe anxiety
Your Anxiety rating
Contact information
ARE YOU AN EXISTING CARENCIA PATIENT?

YesNo
Name*

First NameLast Name
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Should be Empty:

Carencia Anxiety Survey (GAD-7)