Patient's Name * Date of Birth * Phone # * Email * What location are you visiting? * AmherstWilliamsvilleOrchard ParkTonawanda A I feel tense or 'wound up': * Most of the timeA lot of the timeFrom time to time (occ.)Not at all D I still enjoy the things I used to enjoy: * Definitely as muchNot quite as muchOnly a littleHardly at all A I get a sort of frightened feeling as if something awful is about to happen: * Very definitely and quite badlyYes, but not too badlyA little, but it doesn’t worry meNot at all D I can laugh and see the funny side of things: * As much as I always couldNot quite so much nowDefinitely not so much nowNot at all A Worrying thoughts go through my mind: * A great deal of the timeA lot of the timeFrom time to time, but not oftenOnly occasionally D I feel cheerful: * Most of the timeUsuallyNot oftenNot at all A I can sit at ease and feel relaxed: * DefinitelyUsuallyNot oftenNot at all D I feel as if I am slowed down: * Nearly all the timeVery oftenSometimesNot at all A I get a sort of frightened feeling like "butterflies" in the stomach: * Not at allOccasionallyQuite oftenVery often D I have lost interest in my appearance: * DefinitelyI don’t take as much care as I shouldI may not take quite as much careI take just as much care A I feel restless as I have to be on the move: * Very much indeedQuite a lotNot very muchNot at all D I look forward with enjoyment to things: * As much as I ever didRather less than I used toDefinitely less than I used toHardly at all A I get sudden feelings of panic: * Very often indeedQuite oftenNot very oftenNot at all D I can enjoy a good book or radio/TV program: * OftenSometimesNot oftenVery seldom Δ
