Telehealth Anxiety Evaluation Worksheet
Date:
Client Name:
Provider Name:
Anxiety Symptom Rating
Feeling nervous, anxious, or on edge
0 - Not at all
1 - Several days
2 - More than half the days
3 - Nearly every day
Not being able to stop or control worrying
0 - Not at all
1 - Several days
2 - More than half the days
3 - Nearly every day
Worrying too much about different things
0 - Not at all
1 - Several days
2 - More than half the days
3 - Nearly every day
Trouble relaxing
0 - Not at all
1 - Several days
2 - More than half the days
3 - Nearly every day
Being so restless that it's hard to sit still
0 - Not at all
1 - Several days
2 - More than half the days
3 - Nearly every day
Becoming easily annoyed or irritable
0 - Not at all
1 - Several days
2 - More than half the days
3 - Nearly every day
Feeling afraid something awful might happen
0 - Not at all
1 - Several days
2 - More than half the days
3 - Nearly every day
Functional Impact
If you checked any problems above, how difficult have these made it for you to do your work, take care of things at home, or get along with other people?
0 - Not difficult at all
1 - Somewhat difficult
2 - Very difficult
3 - Extremely difficult
Clinical Notes
Observations, comments, and next steps: