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Physical Symptoms

Dear Sir or Madam, please take a few minutes of your time to complete the following questionnaire.

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1

How often in the last 2 weeks have you felt pressure in your head (heavy head)

2

If you have felt this what did you think was causing it?

3

What did you do about it?

4

How often in the last 2 weeks have you felt spaced out or not with it?

5

If you have felt this way, what do you think caused this sensation?

6

What did you do about it?

7

How often in the last 2 weeks have you felt breathless with a tight throat?

8

If you felt this way, what do you think caused this?

9

What did you do about it?

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