Please describe the degree in which you have worried about your life during the past three days. Consider how intense these feelings have been and if they have been there consistently.
Do you get irritated easily? How intense are your feelings of anger?
How well have you slept in the past three days. Please do not take into consideration the use of medications. If you sleep more than usual please mark the box at the bottom.
Do you worry about your health?
Do you worry about little things? Are you worried about something before it has even happened or are you exceedingly anxious?
Do you suffer from any form of phobia?
Do you suffer from any discomfort of the body? i.e. heart-palpitations, excessive sweating, cold hands or feet, dryness of the mouth, gassy stomach etc.
Do you suffer from aches and pains of the body? How severe are they? Do you need to take painkillers? Please do not take into consideration pain or aches caused by injuries and sickness.
Have you suffered from panic attacks in the past three days? If so, how intense?
