Please check the box in the following table after the score that matches the physical and mental symptoms you have had in the last 1 week.
0 No symptoms 1 Mild 2 Moderate 3 Severe 4 Severe
Circle the score that best fits the patient’s situation
Anxious state of mind
0
1
2
3
4
Tension
0
1
2
3
4
Fear
0
1
2
3
4
insomnia
0
1
2
3
4
Cognitive function
0
1
2
3
4
Depressed state of mind
0
1
2
3
4
Somatic anxiety: muscular system
0
1
2
3
4
Somatic anxiety: sensory system
0
1
2
3
4
Cardiovascular system symptoms
0
1
2
3
4
Respiratory symptoms
0
1
2
3
4
Gastrointestinal symptoms
0
1
2
3
4
Genitourinary symptoms
0
1
2
3
4
Vegetative nervous system symptoms
0
1
2
3
4
Behavior during the interview
0
1
2
3
4