1. Do you experience any of the following symptoms: headaches, chest pain, muscle tension, nausea, or changes in sex drive?
NeverRarelySometimesOftenVery Often

2. Do you experience fatigue and/or struggle to fall or stay asleep?
NeverRarelySometimesOftenVery Often

3. Do you worry excessively and feel overwhelmed with responsibilities?
NeverRarelySometimesOftenVery Often

4. Do you struggle to focus on tasks or stay motivated?
NeverRarelySometimesOftenVery Often

5. Do you experience irritability, sadness, or anger?
NeverRarelySometimesOftenVery Often

6. Do you have little appetite or find that you are overeating?
NeverRarelySometimesOftenVery Often

7. Do you struggle to regulate how much caffeine, alcohol, or tobacco you use?
NeverRarelySometimesOftenVery Often

8. Do you withdraw from others or feel overwhelmed in groups of people?
NeverRarelySometimesOftenVery Often

9. Email

10. Name

11. Mobile