Please consider your situation in the previous 30 days and read and answer the questions carefully.  Note that the slider gives you a range of options.  For some questions, the answer options display scores in reverse order.

Please remember to enter your ID and Zip or Postal Code at the end of this survey. 

Thank you!

Question Title

* 1. I feel more nervous and anxious than usual. 

None of the time Most of the time.
i We adjusted the number you entered based on the slider’s scale.

Question Title

* 2. I feel afraid for no reason at all. 

None of the time Most of the time.
i We adjusted the number you entered based on the slider’s scale.

Question Title

* 3. I get upset easily and feel panicky. 

None of the time Most of the time.
i We adjusted the number you entered based on the slider’s scale.

Question Title

* 4. I feel like I'm falling apart and going to pieces. 

None of the time Most of the time.
i We adjusted the number you entered based on the slider’s scale.

Question Title

* 5. I feel that everything is all right and nothing bad will happen.  

MOST of the Time NONE of the Time
i We adjusted the number you entered based on the slider’s scale.

Question Title

* 6. My arms and legs shake and tremble. 

None of the time Most of the time.
i We adjusted the number you entered based on the slider’s scale.

Question Title

* 7. I am bothered by headaches, neck and back pains. 

None of the time Most of the time.
i We adjusted the number you entered based on the slider’s scale.

Question Title

* 8. I feel weak and get tired easily. 

None of the time Most of the time.
i We adjusted the number you entered based on the slider’s scale.

Question Title

* 9. I feel calm and can sit still easily. 

MOST of the Time NONE of the Time
i We adjusted the number you entered based on the slider’s scale.

Question Title

* 10. I can feel my heart beating fast. 

None of the time Most of the time.
i We adjusted the number you entered based on the slider’s scale.

Question Title

* 11. I am bothered by dizzy spells. 

None of the time Most of the time.
i We adjusted the number you entered based on the slider’s scale.

Question Title

* 12. I have dizzy spells or feel faint. 

None of the time Most of the time.
i We adjusted the number you entered based on the slider’s scale.

Question Title

* 13. I can breath in and out easily. 

MOST of the Time NONE of the Time
i We adjusted the number you entered based on the slider’s scale.

Question Title

* 14. I get feelings of numbness and tingling in my fingers and toes. 

None of the time Most of the time.
i We adjusted the number you entered based on the slider’s scale.

Question Title

* 15. I am bothered by stomachaches and indigestion. 

None of the time Most of the time.
i We adjusted the number you entered based on the slider’s scale.

Question Title

* 16. I have to empty my bladder often. 

None of the time Most of the time.
i We adjusted the number you entered based on the slider’s scale.

Question Title

* 17. My hands are usually dry and warm. 

MOST of the Time NONE of the Time
i We adjusted the number you entered based on the slider’s scale.

Question Title

* 18. My face gets hot and blushes. 

None of the time Most of the time.
i We adjusted the number you entered based on the slider’s scale.

Question Title

* 19. I fall asleep easily and get a good night's rest. 

MOST of the time NONE of the time.
i We adjusted the number you entered based on the slider’s scale.

Question Title

* 20. I have nightmares. 

None of the Time Most of the Time
i We adjusted the number you entered based on the slider’s scale.

Question Title

* 21. Your ID and postal code. 

Question Title

* 22. Please enter today's date.

Date / Time
Thank you for your time and participation! 

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