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Time test performed
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Do you feel irritable?
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Do you feel fatigued?
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Do you feel tense?
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Do you have difficulties concentrating?
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Do you have any loss of appetite?
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Do you have any numbness or burning on your face, hands or feet?
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Do you feel your heart racing (palpitations)?
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Does your head feel full or achy?
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Do you feel muscle aches or stiffness?
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Do you feel anxious, nervous or jittery?
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Do you feel upset?
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How restful was your sleep last night?
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Do you feel weak?
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Do you think you didn't have enough sleep last night?
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Do you have any visual disturbances? (sensitivity to light, blurred vision)
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Are you fearful?
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Have you been worrying about possible misfortunes lately?
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Observed sweating, restlessness or agitation
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Observed tremor
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Observed sweaty palms
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Total score:
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Severity- Mild <21, Moderate 21-40, Moderately Severe 41-60, Severe >61
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Assessor
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