For each question CIRCLE the number that best applies to your experience with that symptom over the past 3 months.

0 - Never or rarely – It is rare to experience this symptom.

1 - Occasionally – Once in awhile you may experience this – maybe once or twice a month.

2 - Often – You experience this 1-2 times a week, enough that it bothers you.

3 - Regularly – You are constantly aware of this as it occurs almost every day or weekly.

144. “Lump” in throat

145. Dry mouth

146. Gag easily

147. “Nervous” or “Butterfly” stomach

148. Painful or sensitive nerve(s)

149. Staring, blinks little

150. Muscle-leg-toe cramps at night

151. Blink eyes often

152. Hoarseness frequent

153. Unable to relax; cannot calm

154. Rapid digestion

155. Noises in head or “ringing in ears”

156. Insomnia- can’t stop thinking

157. Nervousness

158. Eyelids and face twitch

159. Strong light irritates

160. Difficulty Swallowing

161. Eyesight, sense of smell and/or taste declining

162. Speaking and forming words feels difficult

163. Weak voice

164. Weak hand grip

165. Hand gets tired when writing, and handwriting is getting smaller

166. Muscles in arms and legs seem smaller and weaker

167. Nervous legs, especially at night

168. Bump into things, trip, stumble and feel clumsy

169. Feet feel heavy as if weighted down when walking

Total Score for Group 6