iwamh-GAD-7 Patient Health Questionnaire

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Patient's Name: *

Patient's Date Of Birth: *

YYYY

Today's Date: *

YYYY

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

0-Not at all

1-Several days

2-More than half the days

3-Nearly every day

1. Feeling nervous, anxious, or on edge

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

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

Source: Primary Care Evaluation of Mental Disorders Patient Health Questionnaire (PRIME-MD-PHQ). The PHQ was developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke, and colleagues. For research information, contact Dr. Spitzer at ris8@columbia.edu. PRIME-MD® is a trademark of Pfizer Inc. Copyright© 1999 Pfizer Inc. All rights reserved.
Reproduced with permission

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