Physical Symptoms |
| Muscle Tension |
0 |
1 |
2 |
3 |
| Feeling
Restless/Shaky |
0 |
1 |
2 |
3 |
| Headaches |
0 |
1 |
2 |
3 |
| Chest
pains |
0 |
1 |
2 |
3 |
| Irregular/unusual
heartbeat |
0 |
1 |
2 |
3 |
| Hard
to get a deep breath |
0 |
1 |
2 |
3 |
| Cold/sweaty
hands or feet |
0 |
1 |
2 |
3 |
| Skin
rash/itch/crawling sensation |
0 |
1 |
2 |
3 |
| Blurred
vision |
0 |
1 |
2 |
3 |
| Dizziness |
0 |
1 |
2 |
3 |
| Belly "knots" or
pain |
0 |
1 |
2 |
3 |
| Nausea |
0 |
1 |
2 |
3 |
| Diarrhea/Gas/Constipation |
0 |
1 |
2 |
3 |
| Frequent
urination |
0 |
1 |
2 |
3 |
| Fatigue/tiredness |
0 |
1 |
2 |
3 |
Behavioural Symptoms |
| Loss
of appetite - or no time to eat |
0 |
1 |
2 |
3 |
| Overeating |
0 |
1 |
2 |
3 |
| Smoking
(to relieve tension) |
0 |
1 |
2 |
3 |
| Alcohol
(more than four drinks per day) |
0 |
1 |
2 |
3 |
| Taking
tranquilizers to relax |
0 |
1 |
2 |
3 |
| Withdrawing
from close relationships |
0 |
1 |
2 |
3 |
| Criticizing
or blaming others |
0 |
1 |
2 |
3 |
| Feeling
victimized or taken advantage of |
0 |
1 |
2 |
3 |
| Watching
TV more than 2 hours per day |
0 |
1 |
2 |
3 |
| Difficulty
meeting commitments |
0 |
1 |
2 |
3 |
| Hard
to pay attention at work |
0 |
1 |
2 |
3 |
Emotional Symptoms |
| Nervous,
uptight, wound up |
0 |
1 |
2 |
3 |
| Cannot
turn off certain thoughts |
0 |
1 |
2 |
3 |
| Worrying
at night |
0 |
1 |
2 |
3 |
| Unable
to keep still/fidgeting |
0 |
1 |
2 |
3 |
| Apathetic
- nothing seems important |
0 |
1 |
2 |
3 |
| Emotionally
drained |
0 |
1 |
2 |
3 |
| Crying
easily |
0 |
1 |
2 |
3 |
| Insomnia |
0 |
1 |
2 |
3 |
| Difficulty
concentrating |
0 |
1 |
2 |
3 |
| Mind
going blank - forgetting things |
0 |
1 |
2 |
3 |
Add up your total and see how you did!
|