Instructions
1. From what you can recall have you ever sleep walked? Yes No 2. Have you ever missed work due to illness for a period of time longer than most people? Yes No 3. Do you have the tendency to feel confused when you are interrupted in the middle of something at work? Yes No 4. Do you feel proud after every difficult accomplishment of yours each day? Yes No 5. From what you recall did you have faith in your abilities the last time that you started to learn something new? Yes No 6. Do daily insignificant problems annoy you? Yes No 7. Have you ever worried for hours after a certain situation that was humiliating for you? Yes No 8. Are there many people who would characterize you as a sensitive person? Yes No 9. Are you usually able to sleep easily and to sleep well? Yes No 10. Would many people consider you shy? Yes No 11. Do you feel neglected or upset if someone you know does not greet you? Yes No 12. Do you feel happy or sad sometimes for no particular reason? Yes No 13. Do you often catch yourself day dreaming when you should be working? Yes No 14. Can you remember if you have had any nightmares during the past five years? Yes No 15. Do you have a real phobia about heights or elevators or tunnels or when walking out through the door? Yes No 16. In emergencies do you usually react with calmness and efficiency? Yes No 17. Do you believe that you are an emotional person in many situations in everyday life? Yes No 18. Do you often worry about your health? Yes No 19. In this last year can you remember any situation where you were really bothering someone? Yes No 20. Do you sweat a lot without performing any physical activity? Yes No 21. During the past five years can you recall your mind going totally blank whilst you were in the middle of doing something that you started? Yes No 22. During the last year have you met at least 3 people who you are sure have been hostile towards you? Yes No 23. Have you ever felt "out of breath" even though you hadn't performed any physical exercise? Yes No 24. Generally are you tolerant of other people's crankiness? Yes No 25. Does a situation exist in your daily life that makes you feel very nervous? Yes No 26. Do you often feel discomfort? Yes No 27. Have you suffered from stomach pain more than once during the last two years? Yes No 28. Do you usually have confidence in yourself? Yes No 29. Do you have any reason to believe that you cannot handle everyday situations in your life as easily as most people? Yes No 30. Have you been using aspirin, sedatives, peptic pills, sleeping pills or other medicine more than once per month during the last six months? Yes No
Yes No
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