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1. How often do you have difficulty falling asleep?
All the time
Often
Sometimes
Rarely
Never
2. Do you suffer from indigestion problems (e.g. peptic ulcer, acid reflux, constipation, etc.)?
Yes
No
3. When you're worried about something, your appetite tends to:
Increase
Decrease
Remain the same
4. Are you currently suffering from high blood pressure?
Yes
No
5. Within the last year, how often did you legitimately call in sick?
Never
1-2 times
3-4 times
5 times or more
6. When dealing with a personal or work-related problem, do you have difficulty concentrating or making decisions?
Yes
Sometimes
No
7. Are you currently suffering from an anxiety or mood disorder (e.g. Generalized Anxiety Disorder, Social Anxiety, Depression, etc.)?
Yes
No
8. Do you experience nausea?
Yes
Sometimes
No
9. Do you find yourself sweating excessively, regardless of the temperature?
Yes
Sometimes
No
10. Do you feel tense or extremely jumpy?
Yes
Sometimes
No
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