For each items below, please place a check mark in the column which best describes how often you felt or behaved this way during the past several days. Finish it less than 10 minutes please. If necessary, show this completely form to your primary care doctor or bring it with you to your office visit.

• 20-44 Normal Range
• 45-59 Mild to Moderate Anxiety Levels
• 60-74 Marked to Severe Anxiety Levels
• 75 and above Extreme Anxiety Levels