Please read each statement and select a number 0, 1, 2 or 3 which indicates how much the statement applied to you over the past week. There are no right or wrong answers. Do not spend too much time on any statement.

The rating scale is as follows:
0: Did not apply to me at all
1: Applied to me to some degree, or some of the time
2: Applied to me to a considerable degree, or a good part of time
3: Applied to me very much, or most of the time

   

0

1

2

3

1.

I found it hard to wind down

 

2.

I was aware of dryness of my mouth

 
 

3.

I couldn’t seem to experience any positive feeling at
all

 
 

4.

I experienced breathing difficulty (eg, excessively
rapid breathing, breathlessness in the absence of physical
exertion)

 
 

5.

I found it difficult to work up the initiative to do
things

 
 

6.

I tended to over-react to situations

 
 

7.

I experienced trembling (eg, in the hands)

 
 

8.

I felt that I was using a lot of nervous energy

 
 

9.

I was worried about situations in which I might panic
and make a fool of myself

 
 

10.

I felt that I had nothing to look forward to

 
 

11.

I found myself getting agitated

 
 

12.

I found it difficult to relax

 
 

13.

I felt down-hearted and blue

 
 

14.

I was intolerant of anything that kept me from getting
on with what I was doing

 
 

15.

I felt I was close to panic

 
 

16.

I was unable to become enthusiastic about anything

 
 

17.

I felt I wasn’t worth much as a person

 
 

18.

I felt that I was rather touchy

 
 

19.

I was aware of the action of my heart in the absence
of physical exertion (eg, sense of heart rate increase,
heart missing a beat)

 
 

20.

I felt scared without any good reason

 
 

21.

I felt that life was meaningless

 
     
 
 

D:

 

 

A:

 

 

S:


Book an Appointment Book An Appointment
Shares