| A |
B |
| Questions about means of relaxation |
Questions about causes of diary anxiety |
| Please circle the appropriate answer in each line |
Please circle the appropriate answer in each line |
| 0: no 1: sometimes yes 2: yes |
0: no 1: sometimes yes 2: yes |
| 1. You have a violent tendency |
0 |
1 |
2 |
1. Crowded commuter train or a long journey to work |
0 |
1 |
2 |
| 2. You are unyielding |
0 |
1 |
2 |
2. Long working hours or overtime |
0 |
1 |
2 |
| 3. You tend to complete with others in everything |
0 |
1 |
2 |
3. Contents of your work |
0 |
1 |
2 |
| 4. You are easily irritated or touchy |
0 |
1 |
2 |
4. Appraisals by others |
0 |
1 |
2 |
| 5. You maintain your opinion |
0 |
1 |
2 |
5. Relationship with your superiors |
0 |
1 |
2 |
| 6. You tend to criticize others |
0 |
1 |
2 |
6. Relationship with your co-workers |
0 |
1 |
2 |
| 7. You are a perfectionist |
0 |
1 |
2 |
7. Social relationship with your men |
0 |
1 |
2 |
| 8. You tend to immerse yourself in anything you do |
0 |
1 |
2 |
8. Your future |
0 |
1 |
2 |
| 9. You forget yourself when you devote yourself to a task |
0 |
1 |
2 |
9. Unemployment or change of employment |
0 |
1 |
2 |
| 10. You tend to rattle off your opinion |
0 |
1 |
2 |
10. Your health |
0 |
1 |
2 |
| 11. You feel you never have enough time |
0 |
1 |
2 |
11. Health of your family |
0 |
1 |
2 |
| 12. You eat or walk quickly |
0 |
1 |
2 |
12. Future of your children |
0 |
1 |
2 |
| 13. You feel uneasy when you take a break |
0 |
1 |
2 |
13. Life in your old age |
0 |
1 |
2 |
| 14. You perform two tasks at once |
0 |
1 |
2 |
14. Communication with your spouse and children |
0 |
1 |
2 |
| 15. You are anxious about what other people think |
0 |
1 |
2 |
15. Supporting your parents |
0 |
1 |
2 |
| 16. You tend to be strained in public |
0 |
1 |
2 |
16. Relationship with your parents or children-in-law |
0 |
1 |
2 |
| 17. You adapt your opinion to the company you are in |
0 |
1 |
2 |
17. Relationship with your friends |
0 |
1 |
2 |
| 18. You strive to meet superior's expectations |
0 |
1 |
2 |
18. Repayment of a loan |
0 |
1 |
2 |
| 19. You swallow your disgust |
0 |
1 |
2 |
19. Sexual relations |
0 |
1 |
2 |
| 20. You tend to avoid bitter situations |
0 |
1 |
2 |
20. Dependency on gambling |
0 |
1 |
2 |
| 21. You blame others when you get into trouble |
0 |
1 |
2 |
21. Dependency on drinking |
0 |
1 |
2 |
| 22. You reproach others when you are in a bad mood |
0 |
1 |
2 |
22. Dealings with your neighbors |
0 |
1 |
2 |
| 23. You worry before you start a task |
0 |
1 |
2 |
|
|
|
|
| 24. You drown your sorrows in alcohol or karaoke |
0 |
1 |
2 |
|
|
|
|
| C |
D |
| Questions about means of relaxation |
Questions about symptoms associated with anxiety |
| Please check all appropriate answers |
Please circle the appropriate answer in each line |
| 1 ( ) You have hobbies |
1 Dry eye |
No |
sometimes |
often |
| 2 ( ) You enjoy sports |
2 Giddiness/fainting |
No |
sometimes |
often |
| 3 ( ) You are an active member of a group/society/club |
3 Muffled hearing/tinnitus |
No |
sometimes |
often |
| 4 ( ) You enjoy the company of good friends |
4 Gastrointestinal distress/ diarrhea |
No |
sometimes |
often |
| 5 ( ) You are valued by your colleagues |
5 Palpitations/excessive perspiration |
No |
sometimes |
often |
| 6 ( ) You enjoy a happy home life |
|
|
|
|
| 7 ( ) You talk over everything with your spouse |
|
|
|
|
| 8 ( ) You have good superiors or colleagues |
|
|
|
|
| 9 ( ) You often go out |
|
|
|
|
| 10 ( ) You enjoy traveling |
|
|
|
|
| 11 ( ) You enjoy dining out or drinking |
|
|
|
|
