Tinnitus E-Programme

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Please read each item and FILL EACH BOX WITH THE NUMBER in the scales below that best describes your experience regarding the INTENSITY (A) and FREQUENCY (B) of these symptoms

A. How INTENSE or BOTHERSOME the symptoms have been IN THE PAST WEEK:

0 = None
1-3 = Mild
4-6 = Moderate
7-9 = Severe
10 = Extreme distress

B. How FREQUENTLY have you experienced the symptoms IN THE PAST WEEK:

0 = Never
1-3 = Occasionally
4-6 = Often
7-9 = Usually
10 = All the time

1. Anxiety

2. Nervousness

3. Worrying

4. Irritability

5. Muscle Tension or Tightness

6. Trouble Relaxing

7. Trouble Falling or Staying Asleep (Rate the most troublesome symptom)

8. Fatigue or Lack of Energy

9. Problems with Concentration or Attention

10. Trouble Remembering Things

11. Shortness of Breath. Chest Tightness or Pain, Pounding/Skipping/Racing Heartbeat (Rate the most troublesome symptom)

12. Stomach Upset, Nausea, Constipation, Diarrhoea, or Irritable Bowels (Rate the most troublesome symptom)

13. Dizziness, Lightheadedness, Headaches, Trembling or Shakiness (Rate the most troublesome symptom)

14. Numbness, Tingling, Excessive Sweating, Flushing or Frequent Urination (Rate the most troublesome symptom)

15. Feeling Restless, Keyed Up, or On Edge

16. Anticipating or Fearing Something Bad Might Happen

17. Trouble Functioning at Home, Work, or Socially due to Anxiety (Rate the most troublesome symptom)

Reference: Baker et al, (2019) Anxiety Symptoms Questionnaire (ASQ): development and validation, General Psychiatry LINK
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Company Director: Debbie Featherstone

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