Nugent Therapy

Patient Name

Patient Email

Patient Phone Number

Location

Over the last 2 weeks, how often have you been bothered by any of the following problems? *

	Not at all	Several days	More than half the days	Nearly every day
Feeling nervous, anxious or on edge
Not being able to stop or control worrying
Worrying too much about different things
Trouble relaxing
Being so restless that it is hard to sit still
Becoming easily annoyed or irritable
Feeling afraid as if something awful might happen