Zung - Nashville Ketamine Clinic Name* First Last Date* MM slash DD slash YYYY Time* : Hours Minutes AM PM AM/PM Email Please Select the Most Appropriate AnswerI feel more nervous and anxious than usual:*None or a Little of the TimeSome of the TimeGood Part of the TimeMost or All of the TimeI feel afraid for no reason at all:*None or a Little of the TimeSome of the TimeGood Part of the TimeMost or All of the TimeI get upset easily or feel panicky:*None or a Little of the TimeSome of the TimeGood Part of the TimeMost or All of the TimeI feel like I'm falling apart and going to pieces:*None or a Little of the TimeSome of the TimeGood Part of the TimeMost or All of the TimeI feel that everything is all right and nothing bad will happen:*None or a Little of the TimeSome of the TimeGood Part of the TimeMost or All of the TimeMy arms and legs shake and tremble:*None or a Little of the TimeSome of the TimeGood Part of the TimeMost or All of the TimeI am bothered by headaches, neck, and back pains:*None or a Little of the TimeSome of the TimeGood Part of the TimeMost or All of the TimeI feel weak and get tired easily:*None or a Little of the TimeSome of the TimeGood Part of the TimeMost or All of the TimeI feel calm and can sit still easily:*None or a Little of the TimeSome of the TimeGood Part of the TimeMost or All of the TimeI can feel my heart beating fast:*None or a Little of the TimeSome of the TimeGood Part of the TimeMost or All of the TimeI am bothered by dizzy spells:*None or a Little of the TimeSome of the TimeGood Part of the TimeMost or All of the TimeI have fainting spells or feel faint:*None or a Little of the TimeSome of the TimeGood Part of the TimeMost or All of the TimeI can breath in and out easily:*None or a Little of the TimeSome of the TimeGood Part of the TimeMost or All of the TimeI get feelings of numbness and tingling in my fingers and toes:*None or a Little of the TimeSome of the TimeGood Part of the TimeMost or All of the TimeI am bothered by stomach aches or indigestion:*None or a Little of the TimeSome of the TimeGood Part of the TimeMost or All of the TimeI have to empty my bladder often:*None or a Little of the TimeSome of the TimeGood Part of the TimeMost or All of the TimeMy hands are usually dry and warm:*None or a Little of the TimeSome of the TimeGood Part of the TimeMost or All of the TimeMy face gets hot and blushes:*None or a Little of the TimeSome of the TimeGood Part of the TimeMost or All of the TimeI fall asleep easily and get a good night's rest:*None or a Little of the TimeSome of the TimeGood Part of the TimeMost or All of the TimeI have nightmares:*None or a Little of the TimeSome of the TimeGood Part of the TimeMost or All of the Time
