Nijmegan Questionnaire Nijmegan Questionnaire:Please fill out all required fields where:0 = NEVER1 = RARELY2 = SOMETIMES3 = OFTEN4 = VERY OFTEN Client Name * First Name Last Name Email CHEST PAIN * 0 - NEVER 1 - RARELY 2 - SOMETIMES 3 - OFTEN 4 - VERY OFTEN BLURRED VISION * 0 - NEVER 1 - RARELY 2 - SOMETIMES 3 - OFTEN 4 - VERY OFTEN DIZZINESS * 0 - NEVER 1 - RARELY 2 - SOMETIMES 3 - OFTEN 4 - VERY OFTEN CONFUSION OR LOSS OF TOUCH WITH REALITY * 0 - NEVER 1 - RARELY 2 - SOMETIMES 3 - OFTEN 4 - VERY OFTEN FAST OR DEEP BREATHING * 0 - NEVER 1 - RARELY 2 - SOMETIMES 3 - OFTEN 4 - VERY OFTEN SHORTNESS OF BREATH * 0 - NEVER 1 - RARELY 2 - SOMETIMES 3 - OFTEN 4 - VERY OFTEN TIGHT FEELINGS IN THE CHEST * 0 - NEVER 1 - RARELY 2 - SOMETIMES 3 - OFTEN 4 - VERY OFTEN BLOATED SENSATION IN STOMACH * 0 - NEVER 1 - RARELY 2 - SOMETIMES 3 - OFTEN 4 - VERY OFTEN TINGLING FINGERS OR HANDS * 0 - NEVER 1 - RARELY 2 - SOMETIMES 3 - OFTEN 4 - VERY OFTEN DIFFICULTY BREATHING OR TAKING DEEP BREATHS * 0 - NEVER 1 - RARELY 2 - SOMETIMES 3 - OFTEN 4 - VERY OFTEN STIFF FINGERS, HANDS, OR ARMS * 0 - NEVER 1 - RARELY 2 - SOMETIMES 3 - OFTEN 4 - VERY OFTEN TIGHT FEELINGS AROUND MOUTH * 0 - NEVER 1 - RARELY 2 - SOMETIMES 3 - OFTEN 4 - VERY OFTEN COLDS HANDS OR FEET * 0 - NEVER 1 - RARELY 2 - SOMETIMES 3 - OFTEN 4 - VERY OFTEN PALPITATIONS IN THE CHEST * 0 - NEVER 1 - RARELY 2 - SOMETIMES 3 - OFTEN 4 - VERY OFTEN FEELING OF ANXIETY * 0 - NEVER 1 - RARELY 2 - SOMETIMES 3 - OFTEN 4 - VERY OFTEN WHAT IS YOUR TOTAL? * Sum the answers of all 15 questions Thank you! Need Help Getting Started?Check out our Health Coaching offering. Learn more
