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TABLE 14-1 U.S. Army Research Institute of Environmental Medicine Environmental Symptoms Questionnaire (ESQ)

Circle the number of each item to correspond to HOW YOU HAVE BEEN FEELING TODAY. PLEASE ANSWER EVERY ITEM. If you did not have the symptom, circle zero (NOT AT ALL).

 

 

Not At All

Slight

Somewhat

Moderate

Quite a Bit

Extreme

1.

I felt lightheaded.

0

1

2

3

4

5

2.

I had a headache.

0

1

2

3

4

5

3.

I felt sinus pressure.

0

1

2

3

4

5

4.

I felt dizzy.

0

1

2

3

4

5

5.

I felt faint.

0

1

2

3

4

5

6.

My vision was dim.

0

1

2

3

4

5

7.

My coordination was off.

0

1

2

3

4

5

8.

I was short of breath.

0

1

2

3

4

5

9.

It was hard to breathe.

0

1

2

3

4

5

10.

It hurt to breathe.

0

1

2

3

4

5

11.

My heart was beating fast.

0

1

2

3

4

5

12.

My heart was pounding.

0

1

2

3

4

5

13.

I had a chest pain.

0

1

2

3

4

5

14.

I had chest pressure.

0

1

2

3

4

5

15.

My hands were shaking or trembling.

0

1

2

3

4

5

16.

I had a muscle cramp.

0

1

2

3

4

5

17.

I had stomach cramps.

0

1

2

3

4

5

18.

My muscles felt tight or stiff.

0

1

2

3

4

5

19.

I felt weak.

0

1

2

3

4

5

20.

My legs or feet ached.

0

1

2

3

4

5

21.

My hands, arms, or shoulder sached.

0

1

2

3

4

5

22.

My back ached.

0

1

2

3

4

5

23.

I had a stomach ache.

0

1

2

3

4

5

24.

I felt sick to my stomach (nauseous).

0

1

2

3

4

5

25.

I had gas pressure.

0

1

2

3

4

5

26.

I had diarrhea.

0

1

2

3

4

5

27.

I felt constipated.

0

1

2

3

4

5

28.

I had to urinate more than usual.

0

1

2

3

4

5

29.

I had to urinate less than usual.

0

1

2

3

4

5

30.

I felt warm.

0

1

2

3

4

5



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