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Please select the number that best represents what you have felt recently for each symptom.

0 – Never | 1 – Rare | 2 – Sometimes | 3 – Often | 4 – Very Often

Chest pain
Feeling tense
Blurred vision
Dizzy spells
Feeling confused
Faster or deeper breathing
Short of breath
Tight feelings in the chest
Bloated feeling in the stomach
Tingling fingers
Unable to breathe deeply
Stiff fingers or arms
Tight feelings around mouth
Cold hands
Palpitations
Feeling of anxiety