1.	Do you feel greatly upset by criticism? Yes No
2.	Do you lose sleep over worry? Yes No
3.	Do you feel upset by the slightest noise? Yes No
4.	Do you feel somewhat uneasy on meeting a member of the opposite sex? Yes No
5.	Do you feel uncomfortable on a conveyance driven at fast speed? Yes No
6.	Do you find life to be a burden and strain? Yes No.
7.	Do you feel uneasy if you have to wait for something? Yes No
8.	Do you fear that you may lose your loved one? Yes No