Please describe how you have felt during the PAST WEEK.
  • Name*full name
    0
  • Email*a valid email address
    1
  • Mark a check mark (√) in the appropriate box. Please answer all questions. Do not think too long before answering.
    2
  • Ratings*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
    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
    3
  • 4