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Physical Symptoms

Cognitive Symptoms

Emotional Symptoms

Results

Have you experienced numbness or tingling?

Not at all

A little

Moderately

A lot

Have you felt hot?

Not at all

A little

Moderately

A lot

Have you experienced wobbliness in your legs?

Not at all

A little

Moderately

A lot

Have you been unable to relax?

Not at all

A little

Moderately

A lot

Have you had fear of the worst happening?

Not at all

A little

Moderately

A lot

Have you felt your heart pounding or racing?

Not at all

A little

Moderately

A lot

Have you experienced shaking?

Not at all

A little

Moderately

A lot

Have you had difficulty breathing?

Not at all

A little

Moderately

A lot

Have you had fear of losing control?

Not at all

A little

Moderately

A lot

Have you had fear of dying?

Not at all

A little

Moderately

A lot

Have you experienced nervousness or shakiness inside?

Not at all

A little

Moderately

A lot

Have you felt a feeling of choking?

Not at all

A little

Moderately

A lot

Have you felt unsteady or lightheaded?

Not at all

A little

Moderately

A lot

Have you experienced trembling?

Not at all

A little

Moderately

A lot

Have you had fear of crowds?

Not at all

A little

Moderately

A lot

Have you experienced blushing?

Not at all

A little

Moderately

A lot

Have you had fear of criticism?

Not at all

A little

Moderately

A lot

Have you felt your heart pounding?

Not at all

A little

Moderately

A lot

Have you been fearful that something awful might happen?

Not at all

A little

Moderately

A lot

Have you had fear of fainting?

Not at all

A little

Moderately

A lot

Have your hands been trembling?

Not at all

A little

Moderately

A lot