Check5 (1) Name *Gender *Phone *Email AddressYour Actual Date Of Birth *Street Address *Apartment, suite, etcCityState/ProvinceZIP / Postal CodeCountry AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaAustraliaArubaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCabo VerdeCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGuernseyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauNorth MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontserratMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSaint HelenaSaint Pierre & MiquelonSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUS Minor Outlying IslandsUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemen Arab Rep.Yemen DemocraticZambiaZimbabweWhy do you feel you have stress ? *0 / 400“Here I have a list of problems people sometimes have. As you read each one, I want you to tell me HOW MUCH THAT PROBLEM HAS DISTRESSED OR BOTHERED YOU DURING THE PAST 7 DAYS INCLUDING TODAY. Select Appropriate answer for each question.1. Nervousness or shakiness inside *Please select an optionNot at allA little bitModeratelyQuite a bitExtremely2. Faintness or dizziness *Please select an optionNot at allA little bitModeratelyQuite a bitExtremely3. The idea that someone else can control your thoughts *Please select an optionNot At AllA Little BitModeratelyQuiet A BitExtremely4. Feeling others are to blame for most of your troubles *Please select an optionNot At AllA Little BitModeratelyQuiet A BitExtremely5. Trouble remembering things *Please select an optionNot At AllA Little BitModeratelyQuiet A BitExtremely6. Feeling easily annoyed or irritated *Please select an optionNot At AllA Little BitModeratelyQuiet A BitExtremely7. Pains in the heart or chest *Please select an optionNot At AllA Little BitModeratelyQuiet A BitExtremely8. Feeling afraid in open spaces *Please select an optionNot At AllA Little BitModeratelyQuiet A BitExtremely9. Thoughts of ending your life *Please select an optionNot At AllA Little BitModeratelyQuiet A BitExtremely“Here I have a list of problems people sometimes have. As you read each one, I want you to tell me HOW MUCH THAT PROBLEM HAS DISTRESSED OR BOTHERED YOU DURING THE PAST 7 DAYS INCLUDING TODAY. Select Appropriate answer for each question.10. Feeling that most people cannot be trusted *Please select an optionNot At AllA Little BitModeratelyQuiet A BitExtremely11. Poor appetite *Please select an optionNot At AllA Little BitModeratelyQuiet A BitExtremely12. Suddenly scared for no reason *Please select an optionNot At AllA Little BitModeratelyQuiet A BitExtremely13. Temper outbursts that you could not control *Please select an optionNot At AllA Little BitModeratelyQuiet A BitExtremely14. Feeling lonely even when you are with people *Please select an optionNot At AllA Little BitModeratelyQuiet A BitExtremely15. Feeling blocked in getting things done *Please select an optionNot At AllA Little BitModeratelyQuiet A BitExtremely16. Feeling lonely *Please select an optionNot At AllA Little BitModeratelyQuiet A BitExtremely17. Feeling blue *Please select an optionNot At AllA Little BitModeratelyQuiet A BitExtremely18. Feeling no interest in things *Please select an optionNot At AllA Little BitModeratelyQuiet A BitExtremely“Here I have a list of problems people sometimes have. As you read each one, I want you to tell me HOW MUCH THAT PROBLEM HAS DISTRESSED OR BOTHERED YOU DURING THE PAST 7 DAYS INCLUDING TODAY. Select Appropriate answer for each question.19. Feeling fearful *Please select an optionNot At AllA Little BitModeratelyQuiet A BitExtremely20. Your feelings being easily hurt *Please select an optionNot At AllA Little BitModeratelyQuiet A BitExtremely21. Feeling that people are unfriendly or dislike you *Please select an optionNot At AllA Little BitModeratelyQuiet A BitExtremely22. Feeling inferior to others *Please select an optionNot At AllA Little BitModeratelyQuiet A BitExtremely23. Nausea or upset stomach *Please select an optionNot At AllA Little BitModeratelyQuiet A BitExtremely24. Feeling that you are watched or talked about by others *Please select an optionNot At AllA Little BitModeratelyQuiet A BitExtremely25. Trouble falling asleep *Please select an optionNot At AllA Little BitModeratelyQuiet A BitExtremely26. Having to check and double check what you do *Please select an optionNot At AllA Little BitModeratelyQuiet A BitExtremely27. Difficulty making decisions *Please select an optionNot At AllA Little BitModeratelyQuiet a BitExtremely“Here I have a list of problems people sometimes have. As you read each one, I want you to tell me HOW MUCH THAT PROBLEM HAS DISTRESSED OR BOTHERED YOU DURING THE PAST 7 DAYS INCLUDING TODAY. Select Appropriate answer for each question.28. Feeling afraid to travel on buses, subways, or trains *Please select an optionNot At AllA Little BitModeratelyQuiet A BitExtremely29. Trouble getting your breath *Please select an optionNot At AllA Little BitModeratelyQuiet A BitExtremely30. Hot or cold spells *Please select an optionNot At AllA Little BitModeratelyQuiet A BitExtremely31. Having to avoid certain things, places, or activities because they frighten you *Please select an optionNot At AllA Little BitModeratelyQuiet A BitExtremely32. Your mind going blank *Please select an optionNot At AllA Little BitModeratelyQuiet A BitExtremely33. Numbness or tingling in parts of your body *Please select an optionNot At AllA Little BitModeratelyQuiet a BitExtremely34. The idea that you should be punished for your sins *Please select an optionNot At AllA Little BitModeratelyQuiet A BitExtremely35. Feeling hopeless about the future *Please select an optionNot At AllA Little BitModeratelyQuiet A BitExtremely36. Trouble concentrating *Please select an optionNot At AllA Little BitModeratelyQuiet A BitExtremely“Here I have a list of problems people sometimes have. As you read each one, I want you to tell me HOW MUCH THAT PROBLEM HAS DISTRESSED OR BOTHERED YOU DURING THE PAST 7 DAYS INCLUDING TODAY. Select Appropriate answer for each question.37. Feeling weak in parts of your body *Please select an optionNot At AllA Little BitModeratelyQuiet A BitExtremely38. Feeling tense or keyed up *Please select an optionNot At AllA Little BitModeratelyQuiet A BitExtremely39. Thoughts of death or dying *Please select an optionNot At AllA Little BitModeratelyQuiet A BitExtremely40. Having urges to beat, injure, or harm someone *Please select an optionNot At AllA Little BitModeratelyQuiet A BitExtremely41. Having urges to break or smash things *Please select an optionNot At AllA Little BitModeratelyQuiet A BitExtremely42. Feeling very self-conscious with others *Please select an optionNot At AllA Little BitModeratelyQuiet A BitExtremely43. Feeling uneasy in crowds *Please select an optionNot At AllA Little BitModeratelyQuiet A BitExtremely44. Never feeling close to another person *Please select an optionNot At AllA Little BitModeratelyQuiet A BitExtremely45. Spells of terror or panic *Please select an optionNot At AllA Little BitModeratelyQuiet A BitExtremely“Here I have a list of problems people sometimes have. As you read each one, I want you to tell me HOW MUCH THAT PROBLEM HAS DISTRESSED OR BOTHERED YOU DURING THE PAST 7 DAYS INCLUDING TODAY. Select Appropriate answer for each question.46. Getting into frequent arguments *Please select an optionNot At AllA Little BitModeratelyQuiet A BitExtremely47. Feeling nervous when you are left alone *Please select an optionNot At AllA Little BitModeratelyQuiet A BitExtremely48. Others not giving you proper credit for your achievements *Please select an optionNot At AllA Little BitModeratelyQuiet A BitExtremely49. Feeling so restless you couldn’t sit still *Please select an optionNot At AllA Little BitModeratelyQuiet A BitExtremely50. Feelings of worthlessness *Please select an optionNot At AllA Little BitModeratelyQuiet A BitExtremely51. Feeling that people will take advantage of you if you let them *Please select an optionNot At AllA Little BitModeratelyQuiet A BitExtremely52. Feeling of guilt *Please select an optionNot At AllA Little BitModeratelyQuiet A BitExtremely53. The idea that something is wrong with your mind *Please select an optionNot At AllA Little BitModeratelyQuiet A BitExtremelySomatization (Max.28)Obsessive - Compulsive Symptomes (Max.24)Interpersoanl Sensitivity (Max.16)Depression (Max.24)Anxiety (Max.24)Hostility (Max.20)Phobic Anxiety (Max. 20)Paranoid Ideation (Max.20)Psychoticism (Max. 20)SubmitPlease do not fill in this field. Our Score Click to rate this post! [Total: 1 Average: 5]
