1 – Not at all
2 – Somewhat
3 – Moderately
4 – Very
5 – Extremely
¹
1
2
3
4
5
1
frightened by this sensation
Heart palpitations
2
Pressure or a heavy feeling in the chest
3
Numbness in the arms or legs
4
Tingling in the fingertips
5
Numbness in another part of your body
6
Feeling short of breath
7
Dizziness
8
Blurred or distorted vision
9
Nausea
10
Having “butterflies” in your stomach
11
Feeling a knot in your stomach
12
Having a lump in your throat
13
Wobbly or rubber legs
14
Sweating
15
A dry throat
16
Feeling disoriented and confused
17
Feeling disconnected from your body: only partly present
The presented answer sheet is not an original form and is not intended for printing or use as a handout.
The answer numbers are used only to label response columns. They are NOT scores and should not be used for calculating results.