1 – This applies to me not at all
2 – This applies to me a little
3 – This applies to me moderately
4 – This applies to me quite a bit
5 – This applies to me extremely
¹
1
2
3
4
5
1
I have pain while urinating.
2
My body, or a part of it, is insensitive to pain.
3
I see things around me differently than usual (for example as if looking through a tunnel, or seeing merely a part of an object).
4
It is as if my body, or a part of it, has disappeared.
5
I cannot speak (or only with great effort) or I can only whisper.
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.