Please indicate the extent to which you are bothered at the moment by any of these symptoms by selecting the appropriate box.
Name
1. Heart beating quickly or strongly?
Not at allA LittleQuite a bitExtremely
2. Feeling tense or nervous?
Not at allA LittleQuite a bitExtremely 3. Difficulty in sleeping?
Not at allA LittleQuite a bitExtremely 4. Excitable?
Not at allA LittleQuite a bitExtremely 5. Attacks of panic?
Not at allA LittleQuite a bitExtremely 6. Difficulty in concentrating?
Not at allA LittleQuite a bitExtremely 7. Feeling tired or lacking in energy?
Not at allA LittleQuite a bitExtremely 8. Loss of interest in most things?
Not at allA LittleQuite a bitExtremely 9. Feeling unhappy or depressed?
Not at allA LittleQuite a bitExtremely 10. Crying spells?
Not at allA LittleQuite a bitExtremely 11. Irritability?
Not at allA LittleQuite a bitExtremely 12. Feeling dizzy or faint?
Not at allA LittleQuite a bitExtremely 13. Pressure or tightness in head or body?
Not at allA LittleQuite a bitExtremely 14. Parts of body feel numb or tingling?
Not at allA LittleQuite a bitExtremely 15. Headaches?
Not at allA LittleQuite a bitExtremely 16. Muscle and joint pains?
Not at allA LittleQuite a bitExtremely 17. Loss of feeling in hands or feet?
Not at allA LittleQuite a bitExtremely 18. Breathing difficulties?
Not at allA LittleQuite a bitExtremely 19. Hot flushes?
Not at allA LittleQuite a bitExtremely 20. Sweating at night?
Not at allA LittleQuite a bitExtremely 21. Loss of interest in sex?