GAD-7 Today's Date MM slash DD slash YYYY Name First Last Client Email (or Parent/Guardian) If you are seeing a medication provider, who will you be seeing today? (Otherwise, skip this question) Dr. Kefalas Angela Pellerito Dannielle Nelson Melanie Troumbly Generalized Anxiety Disorder 7-Item (GAD-7) FormOver the last 2 weeks, how often have you been bothered by the following problems?Feeling nervous, anxious, or on edge Not sure at all - 0 Several Days - 1 Over Half the Days - 2 Nearly Every Day - 3 Not being able to stop or control worry Not sure at all - 0 Several Days - 1 Over Half the Days - 2 Nearly Every Day - 3 Worry too much about different things Not sure at all - 0 Several Days - 1 Over Half the Days - 2 Nearly Every Day - 3 Trouble relaxing Not sure at all - 0 Several Days - 1 Over Half the Days - 2 Nearly Every Day - 3 Being so restless that it’s hard to sit still Not sure at all - 0 Several Days - 1 Over Half the Days - 2 Nearly Every Day - 3 Becoming easily annoyed or irritable Not sure at all - 0 Several Days - 1 Over Half the Days - 2 Nearly Every Day - 3 Feeling afraid as if something awful might happen Not sure at all - 0 Several Days - 1 Over Half the Days - 2 Nearly Every Day - 3 Staff Only: Add the score for each column Staff Only: Add the score for total score If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people? Please check the box next to the one that best describes the level of difficulty. Not at all difficult Somewhat difficult Very Difficult Extremely Difficult If you do not receive a call from a staff within 2 days of submitting your paperwork please contact your local Northland Counseling Center location to ensure they have received your paperwork. Please ensure you click submit.
