Modified Somatic Perceptions Questionnaire

Please describe how you have felt during the PAST WEEK.

Nameyour full name

Emaila valid email

Ratings

	Not at all	A little, slightly	A great deal, quite a bit	Extremely, could not have been worse
Heart rate increase
Feeling hot all over
Sweating all over
Sweating in a particular part of the body
Pulse in neck
Pounding in head
Dizziness
Blurring of vision
Feeling faint
Everything appearing unreal
Nausea
Butterflies in stomach
Pain or ache in stomach
Stomach churning
Desire to pass water
Mouth becoming dry
Difficulty swallowing
Muscles in neck aching
Legs feeling weak
Muscles twitching or jumping
Tense feeling across forehead
Tense feeling in jaw muscles