Tinnitus and hyperacusis therapy specialist unit

Anxiety

Name of the patient:

Your Email Address:

Please type the email address that this form needs to be sent to.
This is often the email address of your clinician who asked you to complete this form.

For each question please select one number based on how you are feeling now.

Over the last 2 weeks, how often have you been bothered by the following problems? (Use “✓” to indicate your answer)	Several Days	More than half the days	Nearly every day
1. Feeling nervous, anxious or on edge	1	2	3
2. Not being able to stop or control worrying	1	2	3
3. Worrying too much about different things	1	2	3
4. Trouble relaxing	1	2	3
5. Being so restless that it is hard to sit still	1	2	3
6. Becoming easily annoyed or irritable	1	2	3
7. Feeling afraid as if something awful might happen.	1	2	3

For Hearing Healthcare Professionals