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Nijmegen Questionnaire

Instructions: Please indicate how often you experience the following symptoms.

0 = NEVER  |  1 = RARELY  |  2 = SOMETIMES  |  3 = OFTEN  |  4 = VERY OFTEN

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Question 1 of 16

Name and Email

Question 2 of 16

CHEST PAIN

(0 = NEVER | 1 = RARELY | 2 = SOMETIMES | 3 = OFTEN | 4 = VERY OFTEN)

A

0

B

1

C

2

D

3

E

4

Question 3 of 16

Blurred Vision

A

0

B

1

C

2

D

3

E

4

Question 4 of 16

Dizziness

A

0

B

1

C

2

D

3

E

4

Question 5 of 16

Confusion or loss of touch with reality

A

0

B

1

C

2

D

3

E

4

Question 6 of 16

Fast or deep breathing

A

0

B

1

C

2

D

3

E

4

Question 7 of 16

Shortness of breath

A

0

B

1

C

2

D

3

E

4

Question 8 of 16

Tight feelings in the chest

A

0

B

1

C

2

D

3

E

4

Question 9 of 16

Bloated sensation in stomach

A

0

B

1

C

2

D

3

E

4

Question 10 of 16

Tingling fingers or hands

A

0

B

1

C

2

D

3

E

4

Question 11 of 16

Difficulty breathing or taking deep breaths

A

0

B

1

C

2

D

3

E

4

Question 12 of 16

Stiff fingers, hands, or arms

A

0

B

1

C

2

D

3

E

4

Question 13 of 16

Tight feelings around mouth

A

0

B

1

C

2

D

3

E

4

Question 14 of 16

Cold hands or feet

A

0

B

1

C

2

D

3

E

4

Question 15 of 16

Palpitations in the chest

A

0

B

1

C

2

D

3

E

4

Question 16 of 16

Feeling of anxiety

A

0

B

1

C

2

D

3

E

4

Confirm and Submit