Download Generalized Anxiety Disorder Questionnaire

Mood and Anxiety Disorders Program
Emory University School of Medicine
Department of Psychiatry and Behavioral Sciences
Generalized Anxiety Disorder Questionnaire
Today’s Date: ____________________
Name: First _______________ MI ___ Last _______________________
Address: ______________________________________________________
City/State/Zip: _______________________________________________
Day Phone#:_________________ Home Phone#:_______________________
O.K. to leave messages? ______ O.K. to leave messages? _____
E-mail address: ____________________
Age: _____ Date of Birth: ____________
Marital Status: Never Married ___ Married ___ Divorced ___ Separated ___ Partnered _
Sex: Male: _____ Female: _____
Name of Person Completing Form (if different):___________________
How did you learn about the study? ______________________________
During the past 6 months:
Have you worried excessively or have you been anxious about a number of things? (e.g.
finances, children’s health, misfortune, work or school performance?)
Yes _____ No _____
Are these worries present most days?
Yes _____ No _____
Do you find it difficult to control the worries, or do they interfere with your ability to focus
on what you are doing?
Yes _____ No _____
During these worried periods when you are anxious do you:
a. Feel restless, keyed up or on edge?
Yes _____
No _____
b. Feel tense or experience muscle aches?
Yes _____
No _____
c. Feel tired, weak or exhausted easily?
Yes _____
No _____
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d. Have difficulty concentrating or
find your mind going blank?
Yes _____
No _____
e. Feel irritable?
Yes _____
No _____
f.
Yes _____
No _____
Have difficulty sleeping?
For how long have you been experiencing these symptoms? ____________
Are you currently receiving treatment for anxiety?
Yes _____ No _____
If yes, what type of treatment are you receiving?
(Please check all that apply)
Medication ___ Psychotherapy ___ Other ___ Not Applicable ___
If you are currently receiving treatment for anxiety, are you satisfied with your level of
improvement?
Yes _____ No _____ Not Applicable _____
Have you ever received any psychotherapy/talk therapy or counseling (including family,
marriage and drug and/or alcohol addiction counseling)?
 Yes _____
No _____

If yes, please list specific start/stop dates and describe type of therapy.
Please list below all medications (past and present) you have taken for anxiety
and/or depression.
*Please note which medications you are currently
taking with a star. (*)
Medication
Dose
Dates
Side Effects
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Effective?
Are you currently taking any prescribed medications other than those for depression or
anxiety?

Yes _____
No _____
If yes, please list all medications (other than those for depression/anxiety) including any
over the counter medications such as Tylenol, Advil, Ibuprofen, sinus/cold medications,
sleep aids, etc. Please note specific start/stop dates.
Medication
Dose
Dates
Reason
Side Effects
Effective?
Are you taking any vitamins, supplements, natural remedies, dietary supplements, herbs,
soy or botanical preparations?
Please note specific start dates.

Yes _____
No _____
If Yes:
Name
Dose
Do you consume caffeine daily?
Dates
Reason
Yes _____
No _____
If yes, please list number of drinks on a daily basis:
_____Coffee
_____Tea
_____Soda
_____Other: Please Explain__________________________________
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Are you now or have you ever been treated for or diagnosed with any other psychiatric
disorder?
_____Major Depression
_____Psychotic Depression
_____Bipolar Disorder (Also known as Manic Depression)
_____Obsessive-Compulsive Disorder
_____Panic Disorder
_____Social Anxiety Disorder
_____Schizophrenia
_____None
Do you have a history of any of the following medical conditions?
Heart problems_____ Bleeding disorder_____ Thyroid Problems____
Prostate problems_____ Blood Pressure problems_____ Cancer_____
Glaucoma ____ Hepatitis ______ Colitis _____ Seizures_______
Head Injury_____

Other_______
None_________
If other, please describe.
Do you drink alcohol?

Yes _____

If yes, how often and how much do you drink?

Has drinking alcohol ever been problem? If so, please describe how.
No _____
Have you ever used or are you currently using illicit (street) drugs?

Yes _____

If yes, please describe use.
No _____
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FOR WOMEN ONLY (noted by *)
*If a female of child bearing potential, are you pregnant or nursing or have you been
pregnant within the past year?

Yes _____
No _____
*If a female of childbearing potential, are you using birth control?

Yes _____
No _____
*If yes, please mark those that apply:
_____Oral contraceptive
*Name of medication and date started ____________________
_____Foam
_____IUD
_____Sponge
_____Diaphragm
_____Condom
_____Partner has vasectomy
_____Other (Please Describe):
*If not currently using birth control:
*It is important that women do not become pregnant during participation in a
study. Therefore, what form of birth control would you be willing to use?
(Note: Abstinence would not be considered an option)
Do you have any known medication allergies or other allergies?

Yes ___

If yes, please describe:
No _____
Have you had any previous surgeries or hospitalizations? (Including outpatient hospital
visits, ER visits, childbirth, hysterectomy and anything that is Psychiatric related)

Yes ___

If yes, please describe and give specific dates.
No _____
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Have you participated in a medication research study within the past 30 days?
Yes ___

No _____
If yes, please describe:
Thank you for your interest. We will be in touch with you after receiving this
questionnaire.
Please send to:
Attn: Studies
Emory University School of Medicine
Mood and Anxiety Disorders Program
1256 Briarcliff Road NE
Building A, 3rd Floor
Atlanta, GA 30322
Phone: (404) 782-MOOD [6663] Fax: (404) 727-3700
E-mail address: [email protected]
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