Indicate how much you have been bothered by each symptom during the past month, including today, by circling the number in the corresponding space in the column next to each symptom.

Not At All

Mildly but it didn’t bother me much.

Moderately―it wasn’t pleasant at times

Severely―it bothered me a lot

Numbness or tingling

0

1

2

3

Feeling hot

0

1

2

3

Wobbliness in legs

0

1

2

3

Unable to relax

0

1

2

3

Fear of worst happening

0

1

2

3

Dizzy or lightheaded

0

1

2

3

Heart pounding/racing

0

1

2

3

Unsteady

0

1

2

3

Terrified or afraid

0

1

2

3

Nervous

0

1

2

3

Feeling of choking

0

1

2

3

Hands trembling

0

1

2

3

Shaky/unsteady

0

1

2

3

Fear of losing control

0

1

2

3

Difficulty in breathing

0

1

2

3

Fear of dying

0

1

2

3

Scared

0

1

2

3

Indigestion

0

1

2

3

Faint / lightheaded

0

1

2

3

Face flushed

0

1

2

3

Hot/cold sweats

0

1

2

3

Column Sum