Questionnaire (Body Senstations)

Hello! Please click the button below to complete a short questionnaire. Doing this regularly is one way we can track how therapy is going. Your responses will be emailed directly to Dr Forzisi.

Below is a list of specific body sensations that may occur when you are nervous or in a feared situation. Please mark down how afraid you are of these feelings. Use a the five point scale below to rate them from '1' not worried to '5' extremely frightened
1. Not frightened or worried by this sensation 2. Somewhat frightened by this sensation 3. Moderately frightened by this sensation 4. Very frightened by this sensation 5. Extremely frightened by this sensation
1. Heart palpitations
2. Pressure or a heavy feeling in chest
3. Numbness in arms or legs
4. Tingling in the fingertips
5. Numbness in another part of your body
6. Feeling short of breath
7. Dizziness
8. Blurred or distorted vision
9. Nausea
10. Having "Butterflies" in your stomach
11. Feeling a knot in your stomach
12. Having a lump in your throat
13. Wobbly or rubber legs
14. Sweating
15. A dry throat
16. Feeling disoriented and confused
17. Feeling disconnected from your body:
18. Only partly present