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Hope . Worth . Destiny

Name *

First Name

Last Name

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

Feeling nervous, anxious or on edge *

0. Not at all

1. Several days

2. More than half the days

3. Nearly every day

Not being able to stop or control everything *

0. Not at all

1. Several days

2. More than half the days

3. Nearly every day

Worrying too much about different things *

0. Not at all

1. Several days

2. More than half the days

3. Nearly every day

Trouble relaxing *

0. Not at all

1. Several days

2. More than half the days

3. Nearly every day

Being so restless that it is hard to sit still *

0. Not at all

1. Several days

2. More than half the days

3. Nearly every day

Being easily annoyed or irritable *

0. Not at all

1. Several days

2. More than half the days

3. Nearly every day

Feeling afraid as if something awful might happen *

0. Not at all

1. Several days

2. More than half the days

3. Nearly every day

Thank you!