Please answer Yes or No to each of the following questions by circling the appropriate letter.

1. Do you have pains in the heart or chest?  Y  N

2. Do you usually belch a lot after eating?  Y  N

3. Do you constantly suffer from bad constipation?  Y  N

4. Do your muscles and joints constantly feel stiff?  Y  N

5. Is your skin very sensitive or tender?  Y  N

6. Do you suffer badly from severe headaches?  Y  N

7. Do you often have spells of severe dizziness?  Y  N

8. Do you usually get tired and exhausted in the morning?  Y  N

9. Do you wear yourself out worrying about your health?  Y  N

10. Do you usually have great difficulty in falling asleep or staying asleep?  Y  N

11. Do strange people or places make you afraid?  Y  N

12. Do you wish you always have someone at your side to advise you?  Y  N

13. Do you usually feel unhappy and depressed?  Y  N

14. Do you often wish you were dead and away from it all?  Y  N

15. Does worrying continually get you down?  Y  N

16. Are you extremely shy or sensitive?  Y  N

17. Does it make you angry to have anyone tell you what to do?  Y  N

18. Do people often annoy or irritate you?  Y  N

19. Do you often shake or tremble?  Y  N

20. Do you often break out in a cold sweat?  Y  N