4DKL

The following questionnaire concerns various complaints and symptoms you may have. It is always about complaints and symptoms you have experienced in the past week (the past 7 days including today). Complaints you had before but no longer in the past week do not count. For each complaint, please indicate how often you have noticed this in the past week by ticking the box that represents the most appropriate answer.

Surname *

Date of birth *

Email address *

Have you suffered in the past week:

Dizziness or feeling light-headed? *

Suffering from aching muscles? *

Fainting? *

Neck pain? *

Back pain? *

Excessive perspiration? *

Heart palpitations? *

Headache? *

A bloated feeling in the stomach? *

Blurred vision or seeing spots in front of the eyes? *

Tightness? *

Nausea or an ‘upset’ stomach? *

Feeling the past week:

Pain in the abdomen or stomach area? *

Tingling in the fingers? *

An oppressive or oppressive feeling in the chest? *

Chest pain? *

Dejection? *

Just a sudden scare? *

Peaking? *

Restless sleep? *

Indefinite anxiety? *

Lustlessness? *

Trembling in the company of other people? *

Anxiety or panic attacks? *

Tense? *

Quickly irritated? *

Anxious? *

Have you been feeling this past week:

That everything is meaningless? *

That you can come to nothing? *

That life is not worth living? *

That you can no longer take an interest in the people and things around you? *

That you can't take it anymore? *

That it would be better if only you were dead? *

That you can no longer enjoy anything? *

That there is no way out of your situation? *

That you can't take it anymore? *

That you don't feel like doing anything anymore? *

Have you spent the past week:

Trouble thinking clearly? *

Trouble getting to sleep? *

Fear of leaving the house alone? *

Have you spent the past week:

Quickly emotional? *

Fearful of something you should not be afraid of at all? (e.g. animals, heights, small spaces) *

Afraid of travelling on buses, trains or trams? *

Afraid of being embarrassed in the company of other people? *

Do you ever feel like you are threatened by an unknown danger? *

Do you ever think 'if only I were dead'? *

Do images sometimes pop into your mind about (a) poignant event(s) you have experienced? *

Do you sometimes have to try your best to get rid of thoughts or memories of (a) poignant event(s)? *

Do you need to avoid certain places because they make you anxious? *

Do you have to repeat some actions several times before you can do anything else? *

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