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Modified Somatic Perceptions Questionnaire – Smart Health Training

Modified Somatic Perceptions Questionnaire

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Modified Somatic Perceptions Questionnaire
Please describe how you have felt during the PAST WEEK.
Nameyour full name
Not at allA little, slightlyA great deal, quite a bitExtremely, 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
Blurring of vision
Feeling faint
Everything appearing unreal
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