Family Service of the Piedmont | Generalized Anxiety
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Do you suffer from Generalized Anxiety Disorder?
(for those 18 and older)

 Ranking Scale:
 1 – Never 2 – Rarely 3 – Sometimes 4 – Frequently 5 – Always

 On a scale of 1 – 5, how would you answer the following questions?

1.

How frequently do you consider yourself excessively anxious and worrisome about a number of events or activities? (Examples include anxiety about finances, job responsibilities, health of family members, misfortune to your children, household chores, car repairs, or being late for appointments.)
1
2
3
4
5

2. Do you have difficulty controlling your worry?
1
2
3
4
5
3. How frequently do you find yourself worrying about everyday concerns?
1
2
3
4
5
4.
How often do you experience any of the following physical symptoms, in addition to feelings of anxiety and worry?

Restlessness or feeling keyed up or on edge?
1
2
3
4
5

Being easily fatigued?
1
2
3
4
5

Difficulty concentrating or mind going blank?
1
2
3
4
5

Irritability?
1
2
3
4
5

Muscle tension?
1
2
3
4
5

Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)?
1
2
3
4
5
5. Does your anxiety, worry, or physical symptoms cause significant distress or impairment for you in your personal or work life, or other important areas of functioning?
1
2
3
4
5




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