Nijmegen Questionnaire
Please answer all questions below. Select how often you experience each symptom.
Chest Pain
*
Never
Rarely
Sometimes
Often
Very Often
Feeling Tense
*
Never
Rarely
Sometimes
Often
Very Often
Blurred Vision
*
Never
Rarely
Sometimes
Often
Very Often
Dizzy Spells
*
Never
Rarely
Sometimes
Often
Very Often
Feeling Confused
*
Never
Rarely
Sometimes
Often
Very Often
Faster or Deeper Breathing
*
Never
Rarely
Sometimes
Often
Very Often
Short of Breath
*
Never
Rarely
Sometimes
Often
Very Often
Tight Feelings in Chest
*
Never
Rarely
Sometimes
Often
Very Often
Bloated Feeling in Stomach
*
Never
Rarely
Sometimes
Often
Very Often
Tingling Fingers
*
Never
Rarely
Sometimes
Often
Very Often
Unable to Breathe deeply
*
Never
Rarely
Sometimes
Often
Very Often
Stiff Fingers or Arms
*
Never
Rarely
Sometimes
Often
Very Often
Tight Feelings around Mouth
*
Never
Rarely
Sometimes
Often
Very Often
Cold Hands or Feet
*
Never
Rarely
Sometimes
Often
Very Often
Heart Racing (palpitations)
*
Never
Rarely
Sometimes
Often
Very Often
Feelings of Anxiety
*
Never
Rarely
Sometimes
Often
Very Often
Total Score
*
Name
First Name
Last Name
Email
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