Email address
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How often do you experience the following physiological sensations:
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Never
Rarely
Sometimes
Often
Very often
Lightheadedness/dizziness
Rapid heartbeat
Feeling of tightness in the chest
Shortness of breath
Faster/deeper breathing
Tingly or numb sensations in your hands or feet
Unpleasant sensations in your stomach (pain, gas, cramps, bloating, “butterflies”)
Feeling shaky
Feeling tense
Cold hands and/or feet
Yawning or sighing frequently
Breathing through your mouth
How often do you experience the following cognitive sensations:
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Never
Rarely
Sometimes
Often
Very often
Difficulty focusing/ “fuzzy” mind
Difficulty staying on task
Feeling confused
Racing thoughts/difficulty calming the mind
Feeling disconnected from your body, as if you are looking over at yourself from above
When you experience a particularly difficult situation, how often does it take you too long to recover?
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Please Select
Never
Rarely
Sometimes
Often
Very often
When you experience intense difficult emotions, such as fear, anxiety, anger, sadness, or shame, how much difficulty do you have in regulating your emotional state and returning to baseline?
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Please Select
A lot of difficulty. I can’t calm down for much too long, feeling interferes with my ability to do other things
Fair amount of difficulty. I get distracted by the feeling from time to time, but able to let go some of the time
Some difficulty. It takes me some time to calm down, but once I do, I stay calm
Little difficulty. I am able to allow my feelings to come and go without getting stuck
I don’t experience these feelings intensely at all
When you have a busy day, how often do you find it difficult to transition from one activity to the next (continue thinking about the previous activity, have trouble focusing on the new one)
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Please Select
Never
Rarely
Sometimes
Often
Always
Imagine that you overhear a friend gossiping about you in a mean way to other friends. What are you likely to do in this situation (pick the scenario that fits best, even if not perfectly):
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Please Select
Feel very hurt. Keep thinking about it over and over for many days, have a lot of trouble letting go of it
Feel hurt. As soon as an opportunity presents itself let the friend know that you heard what s/he said, and ask them to explain what happened
Brush it off. Who cares what other people think?
Get very angry. Confront the friend immediately, never talk to him/her again
Feel very angry. Never mention it to anyone. It eats away at me for a while
How often do difficult experiences (e.g., a fight with a spouse, conflict with a coworker, failure to achieve a goal, not getting what you want, plans falling apart, etc.) in one part of the day spill over and affect how you feel in other parts of your day?
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Please Select
Never
Rarely
Sometimes
Often
Always
Imagine you are leaving your office for a very important meeting with your boss. On the way to the meeting, you have an argument with a colleague. How likely is the argument to throw you off your game for the meeting?
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Please Select
Very unlikely
Some chance
50/50 chance
Quite likely
Almost certainly
In a crisis, or unexpectedly difficult situation, how likely are you to keep calm and focus on figuring out the best way to handle it:
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Please Select
Very unlikely
Possible
50/50 chance
Quite likely
Almost certainly
When difficult or unpleasant things happen, how likely are you to feel that you have the resources to meet the challenge
*
Please Select
Very unlikely
Some chance
50/50 chance
Quite likely
Almost certainly
When difficult or unpleasant things happen, how likely are you to feel overwhelmed and unable to cope?
*
Please Select
Very unlikely
Some chance
50/50 chance
Quite likely
Almost certainly
When you are unable to achieve a goal, how likely are you to blame yourself and “beat up” on yourself emotionally for the failure?
*
Please Select
Very unlikely
Some chance
50/50 chance
Quite likely
Almost certainly
When faced with uncertainty about the future, how likely are you to feel that things will work out well enough?
*
Please Select
Very unlikely
Some chance
50/50 chance
Quite likely
Almost certainly
When things don’t go according to plan, how likely are you to adapt quickly to the changes and respond to the new developments with flexibility?
*
Please Select
Very unlikely
Some chance
50/50 chance
Quite likely
Almost certainly
When you experience a tough set back, how likely are you to respond with constructive action in response?
*
Please Select
Very unlikely
Some chance
50/50 chance
Quite likely
Almost certainly
When having a difficult conversation with a colleague, a friend, or a spouse, how likely are you to feel that you are reacting automatically in unhelpful ways and not able to get your point across
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Please Select
Very unlikely
Some chance
50/50 chance
Quite likely
Almost certainly
When having a difficult conversation with a colleague, a friend, or a spouse, how likely are you to feel that you are communicating and getting your point across effectively?
*
Please Select
Very unlikely
Some chance
50/50 chance
Quite likely
Almost certainly
How often do you find that your mind is not focused on the present, but is lost in replaying or regretting mistakes of the past, anticipating problems of the future, or comparing yourself to others in unpleasant ways?
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Never
Rarely
Sometimes
Often
Always
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