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14

Do you notice a tendency to blush when you are anxious?

Yes No

13

Do you notice (in any excitement) a tendency for your face to pale?

Yes No

12

Do you ever experience numbness or coldness in your fingers or toes?

Yes No

11

Do you ever experience numbness or coldness in your hands or feet?

Yes No

10

Do you experience any change in the color (paleness, redness, blueness) of the fingers of the hands or feet?

Yes No

9

Do you ever experience color changes (paleness, redness, blueness) in the entire hands or feet?

Yes No

8

Do you notice increased sweating?

Yes No

7

Do you often experience a heartbeat sensation, "pausing," or "stopping of the heart"?

Yes No

6

Do you often experience difficulty breathing: a feeling of shortness of breath, rapid breathing?

Yes No

5

Is it characteristic for you to have gastrointestinal dysfunction (tendency to constipation, diarrhea, bloating, pain)?

Yes No

4

Do you experience pre-fainting or fainting episodes?

Yes No

3

Do you experience episodic headaches?

Yes No

2

Are you currently experiencing a decrease in work capacity and quick fatigue?

Yes No

1

Do you notice sleep disturbances?

Yes No