Full Name
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Email
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Age
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1. Heart beating quickly or strongly
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Not at all
A little
Quite a bit
Extremely
2. Feeling tense or nervous
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Not at all
A little
Quite a bit
Extremely
3. Difficulty in sleeping
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Not at all
A little
Quite a bit
Extremely
4. Excitable
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Not at all
A little
Quite a bit
Extremely
5. Attacks of anxiety or panic
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Not at all
A little
Quite a bit
Extremely
6. Difficulty in concentrating
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Not at all
A little
Quite a bit
Extremely
7. Feeling tired or lacking in energy
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Not at all
A little
Quite a bit
Extremely
8. Loss of interest in most things
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Not at all
A little
Quite a bit
Extremely
9. Feeling unhappy or depressed
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Not at all
A little
Quite a bit
Extremely
10. Crying spells
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Not at all
A little
Quite a bit
Extremely
11. Irritability
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Not at all
A little
Quite a bit
Extremely
12. Feeling dizzy or faint
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Not at all
A little
Quite a bit
Extremely
13. Pressure or tightness in head
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Not at all
A little
Quite a bit
Extremely
14. Parts of body feel numb
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Not at all
A little
Quite a bit
Extremely
15. Headaches
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Not at all
A little
Quite a bit
Extremely
16. Muscle or joint pains
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Not at all
A little
Quite a bit
Extremely
17. Loss of feeling in hands or feet
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Not at all
A little
Quite a bit
Extremely
18. Breathing Difficulties
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Not at all
A little
Quite a bit
Extremely
19. Hot Flushes
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Not at all
A little
Quite a bit
Extremely
20. Sweating at Night
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Not at all
A little
Quite a bit
Extremely
21. Loss of interest in Sex
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Not at all
A little
Quite a bit
Extremely