1. Do you experience Numbness or tingling?

Not at all
Mildly, but it didn't bother me much
Moderately - it wasn't pleasant at times
Severely - it bothered me a lot

2. Do you experience Feeling hot?

Not at all
Mildly, but it didn't bother me much
Moderately - it wasn't pleasant at times
Severely - it bothered me a lot

3. Do you experience Wobbliness in legs?

Not at all
Mildly, but it didn't bother me much
Moderately - it wasn't pleasant at times
Severely - it bothered me a lot

4. Do you experience an inability to relax?

Not at all
Mildly, but it didn't bother me much
Moderately - it wasn't pleasant at times
Severely - it bothered me a lot

5. Do you experience a Fear of the worst happening?

Not at all
Mildly, but it didn't bother me much
Moderately - it wasn't pleasant at times
Severely - it bothered me a lot

6. Do you experience Dizzy or lightheadedness?

Not at all
Mildly, but it didn't bother me much
Moderately - it wasn't pleasant at times
Severely - it bothered me a lot

7. Do you experience Heart pounding / racing?

Not at all
Mildly, but it didn't bother me much
Moderately - it wasn't pleasant at times
Severely - it bothered me a lot

8. Do you experience feeling Unsteady?

Not at all
Mildly, but it didn't bother me much
Moderately - it wasn't pleasant at times
Severely - it bothered me a lot

9. Do you experience feeling Terrified or afraid?

Not at all
Mildly, but it didn't bother me much
Moderately - it wasn't pleasant at times
Severely - it bothered me a lot

10. Do you experience feeling Nervous?

Not at all
Mildly, but it didn't bother me much
Moderately - it wasn't pleasant at times
Severely - it bothered me a lot

11. Do you experience Feelings of being choked?

Not at all
Mildly, but it didn't bother me much
Moderately - it wasn't pleasant at times
Severely - it bothered me a lot

12. Do you experience your hands trembling?

Not at all
Mildly, but it didn't bother me much
Moderately - it wasn't pleasant at times
Severely - it bothered me a lot

13. Do you often feel Shaky / unsteady?

Not at all
Mildly, but it didn't bother me much
Moderately - it wasn't pleasant at times
Severely - it bothered me a lot

14. Do you fear losing control?

Not at all
Mildly, but it didn't bother me much
Moderately - it wasn't pleasant at times
Severely - it bothered me a lot

15. Do you experience Difficulty in breathing?

Not at all
Mildly, but it didn't bother me much
Moderately - it wasn't pleasant at times
Severely - it bothered me a lot

16. Do you experience Fear of dying?

Not at all
Mildly, but it didn't bother me much
Moderately - it wasn't pleasant at times
Severely - it bothered me a lot

17. Do you frequently feel Scared?

Not at all
Mildly, but it didn't bother me much
Moderately - it wasn't pleasant at times
Severely - it bothered me a lot

18. Do you experience Indigestion?

Not at all
Mildly, but it didn't bother me much
Moderately - it wasn't pleasant at times
Severely - it bothered me a lot

19. Do you feel Faint / lightheaded?

Not at all
Mildly, but it didn't bother me much
Moderately - it wasn't pleasant at times
Severely - it bothered me a lot

20. Does your Face feel flushed?

Not at all
Mildly, but it didn't bother me much
Moderately - it wasn't pleasant at times
Severely - it bothered me a lot

21. Do you experience Hot / cold sweats?

Not at all
Mildly, but it didn't bother me much
Moderately - it wasn't pleasant at times
Severely - it bothered me a lot