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#1 NEW PATIENT - Mood disorder #2 NEW PATIENT- ADHD assessment #3 NEW PATIENT Health History form #4 NEW PATIENT - PHQ-9 #5 NEW PATIENT Epworth Sleepiness Scale #5 NEW PATIENT Epworth Sleepiness Scale #6 NEW PATIENT CUXOS Anxiety Scale *Binge eating disorder assessment *FOLLOW-UP FORM: Anxiety *FOLLOW-UP FORM: Depression MDQ follow-up Medication renewal form *FOLLOW-UP FORM: ADHD Patient survey

#6 NEW PATIENT CUXOS Anxiety Scale

CUXOS Anxiety Scale:

Name: *

Date: *

During the past week, including today:

1. I felt nervous or anxious *

0 = not at all

1= rarely true

2= sometimes true

3 - often true

4- almost always true

2. I worried a lot that something bad might happen. *

0 = not at all

1= rarely true

2= sometimes true

3 - often true

4- almost always true

3. I worried too much about things *

0 = not at all

1= rarely true

2= sometimes true

3 - often true

4- almost always true

4. I was jumpy and easily startled by noises *

0 = not at all

1= rarely true

2= sometimes true

3 - often true

4- almost always true

5. I felt keyed up or on edge *

0 = not at all

1= rarely true

2= sometimes true

3 - often true

4- almost always true

6. I felt scared *

0 = not at all

1= rarely true

2= sometimes true

3 - often true

4- almost always true

7. I had muscle tension or muscle aches: *

0 = not at all

1= rarely true

2= sometimes true

3 - often true

4- almost always true

8. I felt jittery *

0 = not at all

1= rarely true

2= sometimes true

3 - often true

4- almost always true

9. I was short of breath *

0 = not at all

1= rarely true

2= sometimes true

3 - often true

4- almost always true

10. My heart was pounding or racing *

0 = not at all

1= rarely true

2= sometimes true

3 - often true

4- almost always true

11. I had cold, clammy hands *

0 = not at all

1= rarely true

2= sometimes true

3 - often true

4- almost always true

12. I had a dry mouth *

0 = not at all

1= rarely true

2= sometimes true

3 - often true

4- almost always true

13. I was dizzy or light-headed *

0 = not at all

1= rarely true

2= sometimes true

3 - often true

4- almost always true

14. I felt sick to my stomach (nauseated) *

0 = not at all

1= rarely true

2= sometimes true

3 - often true

4- almost always true

15. I had diarrhea *

0 = not at all

1= rarely true

2= sometimes true

3 - often true

4- almost always true

16. I had hot flashes or chills *

0 = not at all

1= rarely true

2= sometimes true

3 - often true

4- almost always true

17. I urinated frequently *

0 = not at all

1= rarely true

2= sometimes true

3 - often true

4- almost always true

18. I felt a lump in my throat: *

0 = not at all

1= rarely true

2= sometimes true

3 - often true

4- almost always true

19. I was sweating *

0 = not at all

1= rarely true

2= sometimes true

3 - often true

4- almost always true

20. I had tingling feelings in my fingers or feet *

0 = not at all

1= rarely true

2= sometimes true

3 - often true

4- almost always true

* Required field