Questionnaire for Identifying Signs of Autonomic Changes Test - the question form
Questions: 11 · 3 minutes
1. When you feel anxious or worried, do you tend to:
have your face become flushed
have your face turn pale
this does not happen
2. Do you experience numbness or coldness in:
the fingers or toes
the whole hands or feet
I do not experience this
3. Do you have changes in skin color (paleness, redness, bluish discoloration)?
of the fingers or toes
of the hands or feet as a whole
does not occur
4. Do you have increased sweating?
Yes
No
5. Do you often have sensations of a racing heartbeat, skipped beats, or your heart stopping?
Yes
No
6. Do you often experience difficulty breathing, such as feeling short of breath or breathing rapidly?
Yes
No
7. Do you have gastrointestinal problems, such as a tendency toward constipation, diarrhea, abdominal bloating, or pain?
Yes
No
8. Do you ever faint (sudden loss of consciousness) or feel as though you might faint?
Yes
No
9. Do you have episodes of headache that come in attacks?
Yes
No
10. Are you currently experiencing reduced ability to work or becoming fatigued quickly?
Yes
No
11. Do you experience sleep disturbances?
Difficulty falling asleep
Light, shallow sleep with frequent awakenings
Feeling unrefreshed or tired on waking in the morning
No