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Screening Form (1)
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Participant's First and Last Name
*
Your answer
Over the
last two weeks
, how often have you been bothered by the following problems?
1. Feeling nervous, anxious, or on edge
*
Not at all - 0
Several days - 1
More than half the days - 2
Nearly every day - 3
2. Not being able to stop or control worrying
*
Not at all - 0
Several days - 1
More than half the days - 2
Nearly every day - 3
3. Worrying too much about different things
*
Not at all - 0
Several days - 1
More than half the days - 2
Nearly every day - 3
4. Trouble relaxing
*
Not at all - 0
Several days - 1
More than half the days - 2
Nearly every day - 3
5. Being so restless that it is hard to sit still
*
Not at all - 0
Several days - 1
More than half the days - 2
Nearly every day - 3
6. Becoming easily annoyed or irritable
*
Not at all - 0
Several days - 1
More than half the days - 2
Nearly every day - 3
7. Feeling afraid, as if something awful might happen
*
Not at all - 0
Several days - 1
More than half the days - 2
Nearly every day - 3
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 all
Somewhat difficult
Very difficult
Extremely difficult
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