Below is a list of physiological symptoms that people sometimes experience when they are feeling anxious or panicky. Please rate on the line next to each item how fearful you are of these symptoms using the numbers from 0 to 3 below. Please rate each item.
- N/A – Symptom not present
- 0 – Not at all fearful
- 1 – Somewhat fearful
- 2 – Quite fearful
- 3 – Extremely fearful
____ 1. Lightheadedness / dizziness
_____ 2. Shortness of breath
_____ 3. Wobbliness in legs
____ 4. Nausea
____ 5. Blurred / distorted vision
____ 6. Tingling in fingertips
____ 7. Numbness in arms or legs
____ 8. Heart palpitations
____ 9. Pressure / heaviness in chest
____ 10. Knot in stomach
____ 11. Lump in throat
____ 12. Dry throat
____ 13. Sweating
____ 14. Disorientation / confusion
____ 15. Sense of disconnectedness from body
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