How often do you get sick with the cold‚ flu‚ or similar common illness? (circle the number of the most accurate response):
1 = less than once a year‚ 2 =once or twice a year‚ 3 = three or four times a year‚ 4 =more than four times a year
Have you ever been diagnosed with the following (circle the appropriate response):
Please list medications you are currently taking (including oral contraceptives):
You will be presented with several common physical difficulties that people experience followed by three columns. Column A is concerned with how frequently you experience these difficulties. You are to circle a number to indicate how frequently you experience the difficulties. Column B is concerned with how much of an impact the difficulties have on your life. You are to circle a number to indicate the impact of the physical problems. Column C is concerned with what kinds of moods or emotions contribute to the physical difficulties. You are to place a check-mark in as many ‚of the boxes as necessary to represent the emotional states that seem to lead to the physical problems. See the example below:
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A |
B |
C |
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Migraine headache Headache Nausea or upset stomach Numbness or tingling |
3 4 2 0 |
3 2 4 0 |
X x |
x |
X |
Column-A: How frequently do you have the following problems? “0 =I have never had this problem‚ 1= less than once month‚ 2= once or twice month‚ 3=three or four times a month‚ and 4=more than four times a month”
Column-B: How much does this problem affect you? “0=Never a problem at all‚ 1=Barely noticeable; not a problems‚ 2= A minor problem; small discomfort‚ 3= A problem; but can be dealt with‚ 4= Huge negative impact on my life”.
Column – C: I have these problems when I feel … (Check All That Apply) “Stressed‚ anxious‚ frightened‚ or worried‚” “depressed‚ lonely‚ empty‚ or sad‚” “angry‚ irritated‚ mad‚ or agitated.”
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A |
B |
C |
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Migraine headache Headache Nausea or upset stomach Numbness or tingling Trouble breathing or short of breath Stomach aches or pains Shakiness or trembling Difficulty sleeping Vomiting Heart pounding or racing Diarrhea Blackouts or fainting Cramps Backaches Appetite problems Leg or foot pain Dizziness Fatigue or weakness Indigestion Impotence (males) Chest pain Blurred vision Nose bleeds Diffuse body aches and pains Constipation Hot or cold spells Skin rash Pain or aches in arms or hands Genital/Sexual Pain Cold sores or fever blisters Twitching of eyelid Premature ejaculation (males) Heartburn Ulcer Ringing in ears Dry or red eyes Absence of menstruation (females) Acne Muscle tension Severe PMS (females) Inability to achieve orgasm Excessive energy |
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This instrument can be found at: http://trace.tennessee.edu/utk_interstp2/108 trace.tennessee.edu/cgi/viewcontent.cgi?article=1107&context=utk_interstp2
Borckardt‚ J.J.‚ Younger‚ J.W.‚ Adams‚ B.J.‚ Nash‚ M.R. (2000). Toward a better understanding of the relationship between somatization and hypnotizabilility. Paper presented at the meeting of the Society for Clinical and Experimental Hypnosis‚ Seattle‚ WA.
Borckardt‚ Jeffrey J. (2002). Physiological reactivity to mental imagery as a predictor of somatization and psychopathology. University of Tennessee. Doctoral Dissertation
Willis‚ Leah‚ “Self-efficacy‚ Psychosomatic Illness‚ and Psychopathology” (2002). Senior Thesis Projects‚ 1993-2002. http://trace.tennessee.edu/utk_interstp2/108