Tricity Family Medicine & Urgent Care

Patient's First Name * Patient's Last Name * Date of Birth * Todays Date *

Over the last 2 weeks, how often have you been bothered by the following problems?

1. Feeling nervous, anxious, or on edge * 2. Not being able to stop or control worrying * 3. Worriying too much about different things * 4. Trouble relaxing * 5. Being so restless that it's hard to still still * 6. Becoming easily annoyed or irritable * 7. Feeling afraid as if something awful might happen * If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with people? * FOR OFFICE CODING= TOTAL SCORE