1. Numbness or tingling * Please select one of the options below (0) Not At All (1) Mildly but it didn’t bother me much (2) Moderately - it wasn’t pleasant at times (3) Severely – it bothered me a lot
2. Feeling hot * Please select one of the options below (0) Not At All (1) Mildly but it didn’t bother me much (2) Moderately - it wasn’t pleasant at times (3) Severely – it bothered me a lot
3. Wobbliness in legs * Please select one of the options below (0) Not At All (1) Mildly but it didn’t bother me much (2) Moderately - it wasn’t pleasant at times (3) Severely – it bothered me a lot
4. Unable to relax * Please select one of the options below (0) Not At All (1) Mildly but it didn’t bother me much (2) Moderately - it wasn’t pleasant at times (3) Severely – it bothered me a lot
5. Fear of worst happening * Please select one of the options below (0) Not At All (1) Mildly but it didn’t bother me much (2) Moderately - it wasn’t pleasant at times (3) Severely – it bothered me a lot
6. Dizzy or lightheaded * Please select one of the options below (0) Not At All (1) Mildly but it didn’t bother me much (2) Moderately - it wasn’t pleasant at times (3) Severely – it bothered me a lot
7. Heart pounding/racing * Please select one of the options below (0) Not At All (1) Mildly but it didn’t bother me much (2) Moderately - it wasn’t pleasant at times (3) Severely – it bothered me a lot
8. Unsteady * Please select one of the options below (0) Not At All (1) Mildly but it didn’t bother me much (2) Moderately - it wasn’t pleasant at times (3) Severely – it bothered me a lot
9. Terrified or afraid * Please select one of the options below (0) Not At All (1) Mildly but it didn’t bother me much (2) Moderately - it wasn’t pleasant at times (3) Severely – it bothered me a lot
10. Nervous * Please select one of the options below (0) Not At All (1) Mildly but it didn’t bother me much (2) Moderately - it wasn’t pleasant at times (3) Severely – it bothered me a lot
11. Feeling of choking * Please select one of the options below (0) Not At All (1) Mildly but it didn’t bother me much (2) Moderately - it wasn’t pleasant at times (3) Severely – it bothered me a lot
12. Hands trembling * Please select one of the options below (0) Not At All (1) Mildly but it didn’t bother me much (2) Moderately - it wasn’t pleasant at times (3) Severely – it bothered me a lot
13. Shaky / unsteady * Please select one of the options below (0) Not At All (1) Mildly but it didn’t bother me much (2) Moderately - it wasn’t pleasant at times (3) Severely – it bothered me a lot
14. Fear of losing control * Please select one of the options below (0) Not At All (1) Mildly but it didn’t bother me much (2) Moderately - it wasn’t pleasant at times (3) Severely – it bothered me a lot
15. Difficulty in breathing * Please select one of the options below (0) Not At All (1) Mildly but it didn’t bother me much (2) Moderately - it wasn’t pleasant at times (3) Severely – it bothered me a lot
16. Fear of dying * Please select one of the options below (0) Not At All (1) Mildly but it didn’t bother me much (2) Moderately - it wasn’t pleasant at times (3) Severely – it bothered me a lot
17. Scared * Please select one of the options below (0) Not At All (1) Mildly but it didn’t bother me much (2) Moderately - it wasn’t pleasant at times (3) Severely – it bothered me a lot
18. Indigestion * Please select one of the options below (0) Not At All (1) Mildly but it didn’t bother me much (2) Moderately - it wasn’t pleasant at times (3) Severely – it bothered me a lot
19. Faint/lightheaded * Please select one of the options below (0) Not At All (1) Mildly but it didn’t bother me much (2) Moderately - it wasn’t pleasant at times (3) Severely – it bothered me a lot
20. Face flushed * Please select one of the options below (0) Not At All (1) Mildly but it didn’t bother me much (2) Moderately - it wasn’t pleasant at times (3) Severely – it bothered me a lot
21. Hot/cold sweats * Please select one of the options below (0) Not At All (1) Mildly but it didn’t bother me much (2) Moderately - it wasn’t pleasant at times (3) Severely – it bothered me a lot
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