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Never Sometimes Often Constantly How often do you feel that your worry is out of your control? Never Sometimes Often Constantly How often do you have troubles sleeping? Never Sometimes Often Constantly Intense anxiety can last up to or more than 15 minutes. In the past 3 months have you experienced Heart would pound, skip a beat, or race No Yes, moderate Yes, severe Severely sweating No Yes, moderate Yes, severe Body was shaking and trembling No Yes, moderate Yes, severe Had difficulty catching my breath, felt overwhelmed No Yes, moderate Yes, severe Felt like you were having a heart attack No Yes, moderate I felt like I was going to die No Yes, moderate Yes, severe How often do you experience panic and/or anxiety attacks Daily Weekly Monthly Often, but less often than monthly I feel fear, guilt, or shame Yes No Lost interest in favorite activities Yes No I become irritable or enraged over minor issues Yes No Many days are sad, lack of joy and peace Yes No I feel very tired most of the time Yes No It is becoming more difficult to function in my social life, personal life and work Yes No How often do you drink alcohol? Never A few times a year A few times a month A few times a week Daily How often do you use Cannabis? Never A few times a year A few times a month A few times a week Daily In the last 6 months, have you used Opiod’s (heroin, codeine, morphine, ocycodone)? No, never No, but I use them a few times a year Yes, I use them a few times a year Yes, a few times a month Yes, a few times a week yes, daily In the last 6 months, have you used Valium, xanax? No, never No, but I use them a few times a year Yes, I use them a few times a year Yes, a few times a month Yes, a few times a week yes, daily Have you ever been diagnosed with (select all that apply) Heart disease Seizures Obesity Mood Disorders Hypertension Personality Disorders Diabetes Social Isolation By checking the box, you indicate you have been diagnosed with this issue. Radio Buttons Option 1 Option 2 Section If you are human, leave this field blank. ContinueSubmit Use Shift+Tab to go back Yes, I have been here before Please Schedule appointment below. The suggested donation for this donation is $$$$$. 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