For each item below, please check the column which best describes how often you felt or behaved this way during the past several days.

  A little of the time Some of the time Good part of the time Most of the time
1. I feel more nervous and anxious than usual.
2. I feel afraid for no reason at all.
3. I get upset easily or feel panicky.
4. I feel like I’m falling apart and going to pieces.
5. I feel that everything is all right and nothing bad will happen.
6. My arms and legs shake and tremble.
7. I am bothered by headaches neck and back pain.
8. I feel weak and get tired easily.
9. I feel calm and can sit still easily.
10. I can feel my heart beating fast.
11. I am bothered by dizzy spells.
12. I have fainting spells or feel like it.
13. I can breathe in and out easily.
14. I get numbness and tingling in my fingers and toes.
15. I am bothered by stomach aches or indigestion.
16. I have to empty my bladder often.
17. My hands are usually dry and warm.
18. My face gets hot and blushes.
19. I fall asleep easily and get a good night’s rest.
20. I have nightmares.
Sources
  1. . . 12(6): Psychosomatics 371-379. .