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Modified Somatic Perception Questionnaire (Anxiety)
Jared Larsen
2020-09-22T16:49:24+00:00
Modified Somatic Perception Questionnaire (Anxiety)
Step
1
of
3
33%
Name
*
Name
First
Last
Please select your case manager
*
Please select your case manager
Choose one
Alma Orozco
Ashley Orozco
Bree Campbell
Brenda Rodriguez
Chase Dunakin
Chase Hebdon
Cindy Joyner
Elizabeth Miller
Hailey Moore
Jared Larsen
Jose Nava
Josh Esteron
Lucero Sanchez
Luis Cruz
Maria Martinez
Michele Mesaros
Monica Guerrero
Nathan Perdue
Veronica Barajas
Other
Instructions
Please describe how you have felt during the PAST WEEK. Please answer all questions. Do not think too long before answering.
Heart rate increase
*
Heart rate increase
Not at all
A little, slightly
A great deal, quite a bit
Extremely, could not have been worse
Feeling hot all over
*
Feeling hot all over
Not at all
A little, slightly
A great deal, quite a bit
Extremely, could not have been worse
Sweating all over
*
Sweating all over
Not at all
A little, slightly
A great deal, quite a bit
Extremely, could not have been worse
Sweating in a particular part of the body
*
Sweating in a particular part of the body
Not at all
A little, slightly
A great deal, quite a bit
Extremely, could not have been worse
Pulse in neck
*
Pulse in neck
Not at all
A little, slightly
A great deal, quite a bit
Extremely, could not have been worse
Pounding in head
*
Pounding in head
Not at all
A little, slightly
A great deal, quite a bit
Extremely, could not have been worse
Dizziness
*
Dizziness
Not at all
A little, slightly
A great deal, quite a bit
Extremely, could not have been worse
Blurring of vision
*
Blurring of vision
Not at all
A little, slightly
A great deal, quite a bit
Extremely, could not have been worse
Feeling faint
*
Feeling faint
Not at all
A little, slightly
A great deal, quite a bit
Extremely, could not have been worse
Everything appearing unreal
*
Everything appearing unreal
Not at all
A little, slightly
A great deal, quite a bit
Extremely, could not have been worse
Nausea
*
Nausea
Not at all
A little, slightly
A great deal, quite a bit
Extremely, could not have been worse
Butterflies in stomach
*
Butterflies in stomach
Not at all
A little, slightly
A great deal, quite a bit
Extremely, could not have been worse
Pain or ache in stomach
*
Pain or ache in stomach
Not at all
A little, slightly
A great deal, quite a bit
Extremely, could not have been worse
Stomach churning
*
Stomach churning
Not at all
A little, slightly
A great deal, quite a bit
Extremely, could not have been worse
Desire to pass water
*
Desire to pass water
Not at all
A little, slightly
A great deal, quite a bit
Extremely, could not have been worse
Mouth becoming dry
*
Mouth becoming dry
Not at all
A little, slightly
A great deal, quite a bit
Extremely, could not have been worse
Difficulty swallowing
*
Difficulty swallowing
Not at all
A little, slightly
A great deal, quite a bit
Extremely, could not have been worse
Muscles in neck aching
*
Muscles in neck aching
Not at all
A little, slightly
A great deal, quite a bit
Extremely, could not have been worse
Legs feeling weak
*
Legs feeling weak
Not at all
A little, slightly
A great deal, quite a bit
Extremely, could not have been worse
Muscles twitching or jumping
*
Muscles twitching or jumping
Not at all
A little, slightly
A great deal, quite a bit
Extremely, could not have been worse
Tense feeling across forehead
*
Tense feeling across forehead
Not at all
A little, slightly
A great deal, quite a bit
Extremely, could not have been worse
Tense feeling in jaw muscles
*
Tense feeling in jaw muscles
Not at all
A little, slightly
A great deal, quite a bit
Extremely, could not have been worse
Medication
Please list all the medication you are taking for your injury
Please list the name of each medication. The frequency you are taking it. (e.g. 1x daily or 3x weekly etc.) and the duration. (How long have you been taking it.)
Medicine Name
Frequency
Duration
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Modified Somatic Perception Questionnaire (Anxiety)