First Name Initial* Middle Name Initial Last Name Initial*
1. Feeling nervous, anxious, or on edge?
0Not at all
1Several days
2Over half the days
3Nearly every day
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?
8. 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?
0Not difficult at all
1Somewhat difficult
2Very difficult
3Extremely difficult
