1 - Before we get started, how are you feeling today?*

2 - Over the past 2 weeks, how often have you felt nervous, anxious, or on edge?*

3 - Over the past 2 weeks, how often have you been not able to stop or control worrying?*

4 - Over the past 2 weeks, how often have you worried too much about different things?*

5 - Over the past 2 weeks, how often have you had trouble relaxing?*

6 - Over the past 2 weeks, how often have you been so restless that it is hard to sit still?*

7 - Over the past 2 weeks, how often have you become easily annoyed or irritated?*

8 - Over the past 2 weeks, how often have you felt afraid as if it something awful might happen?*

9 - "Over the past 2 weeks, how difficult has it been for you to do your work, take care of things at home, or get along with other people? "*

10 - When did the symptoms first begin?*

11 - Have you ever used any of the following mental health medications in the past?*

12 - Was your past treatment effective?

13 - Do you take any medicines, vitamins, or supplements?

14 - Do you smoke or use other tobacco products?*

15 - How many alcoholic beverages do you drink per week?*

16 - Have you had more than 5 drinks at one time in a row sometime over the past 30 days?*

17 - Have you been diagnosed with, or have a history of, any mental health conditions?

18 - "Do you have a family history of any mental health conditions? "*

19 - Do you have or have you ever had any of the following conditions?*

20 - Please list any additional medical conditions, surgeries, or hospitalizations you have had.

21 - Please list any allergies you have.

22 - Is there anything else related to the treatment that you'd like to ask or discuss with your medical provider?

23 - Do you have a preferred treatment? *

24 - Please enter preferred pharmacy information.*