BAI Name First Last Date MM slash DD slash YYYY Numbness or tingling 0 NOT AT ALL 1 MILDLY (It did not bother me much) 2 MODERATELY (It was very unpleasant, but I could stand it) 3 SEVERELY (I could barely stand it) Feeling hot 0 NOT AT ALL 1 MILDLY (It did not bother me much) 2 MODERATELY (It was very unpleasant, but I could stand it) 3 SEVERELY (I could barely stand it) Wobbliness in legs 0 NOT AT ALL 1 MILDLY (It did not bother me much) 2 MODERATELY (It was very unpleasant, but I could stand it) 3 SEVERELY (I could barely stand it) Unable to relax 0 NOT AT ALL 1 MILDLY (It did not bother me much) 2 MODERATELY (It was very unpleasant, but I could stand it) 3 SEVERELY (I could barely stand it) Fear of the worst happening 0 NOT AT ALL 1 MILDLY (It did not bother me much) 2 MODERATELY (It was very unpleasant, but I could stand it) 3 SEVERELY (I could barely stand it) Dizzy or lightheaded 0 NOT AT ALL 1 MILDLY (It did not bother me much) 2 MODERATELY (It was very unpleasant, but I could stand it) 3 SEVERELY (I could barely stand it) Heart pounding or racing 0 NOT AT ALL 1 MILDLY (It did not bother me much) 2 MODERATELY (It was very unpleasant, but I could stand it) 3 SEVERELY (I could barely stand it) Unsteady 0 NOT AT ALL 1 MILDLY (It did not bother me much) 2 MODERATELY (It was very unpleasant, but I could stand it) 3 SEVERELY (I could barely stand it) Terrified 0 NOT AT ALL 1 MILDLY (It did not bother me much) 2 MODERATELY (It was very unpleasant, but I could stand it) 3 SEVERELY (I could barely stand it) Nervous 0 NOT AT ALL 1 MILDLY (It did not bother me much) 2 MODERATELY (It was very unpleasant, but I could stand it) 3 SEVERELY (I could barely stand it) Feeling of choking 0 NOT AT ALL 1 MILDLY (It did not bother me much) 2 MODERATELY (It was very unpleasant, but I could stand it) 3 SEVERELY (I could barely stand it) Hands trembling 0 NOT AT ALL 1 MILDLY (It did not bother me much) 2 MODERATELY (It was very unpleasant, but I could stand it) 3 SEVERELY (I could barely stand it) Shaky 0 NOT AT ALL 1 MILDLY (It did not bother me much) 2 MODERATELY (It was very unpleasant, but I could stand it) 3 SEVERELY (I could barely stand it) Fear of losing control 0 NOT AT ALL 1 MILDLY (It did not bother me much) 2 MODERATELY (It was very unpleasant, but I could stand it) 3 SEVERELY (I could barely stand it) Difficulty breathing 0 NOT AT ALL 1 MILDLY (It did not bother me much) 2 MODERATELY (It was very unpleasant, but I could stand it) 3 SEVERELY (I could barely stand it) Fear of dying 0 NOT AT ALL 1 MILDLY (It did not bother me much) 2 MODERATELY (It was very unpleasant, but I could stand it) 3 SEVERELY (I could barely stand it) Scared 0 NOT AT ALL 1 MILDLY (It did not bother me much) 2 MODERATELY (It was very unpleasant, but I could stand it) 3 SEVERELY (I could barely stand it) Indigestion or discomfort in abdomen 0 NOT AT ALL 1 MILDLY (It did not bother me much) 2 MODERATELY (It was very unpleasant, but I could stand it) 3 SEVERELY (I could barely stand it) Faint 0 NOT AT ALL 1 MILDLY (It did not bother me much) 2 MODERATELY (It was very unpleasant, but I could stand it 3 SEVERELY (I could barely stand it) Face flushed 0 NOT AT ALL 1 MILDLY (It did not bother me much) 2 MODERATELY (It was very unpleasant, but I could stand it) 3 SEVERELY (I could barely stand it) Sweating (not due to heat) 0 NOT AT ALL 1 MILDLY (It did not bother me much) 2 MODERATELY (It was very unpleasant, but I could stand it) 3 SEVERELY (I could barely stand it) CAPTCHA
