Anxiety Assessment Please enable JavaScript in your browser to complete this form.DateFirst Occurrence Date: Approximate Date You Developed a Problem with Your MemoryFeeling Depressed?YesNoIf depressed, how often do you feel that way?RarelySometimesOftenVery OftenDo you feel irritatedRarelySometimesOftenVery OftenHow Would You Rate Your Anxiety on a Scale of 1-10? 10 being worstRate 1 out of 10Rate 2 out of 10Rate 3 out of 10Rate 4 out of 10Rate 5 out of 10Rate 6 out of 10Rate 7 out of 10Rate 8 out of 10Rate 9 out of 10Rate 10 out of 10Anxiety is a common complaint of Long-haulers. How Anxious are you Right Now?Did You Have Trouble Sleeping Last Night?YesNoAre You Sleeping More Than NormalYesNoTrouble Concentration?YesNoDo You Have Problems with tasks or lose track of what you are doing?Submit