Name *

Contact Number *

Email Address *

Actual Date of Birth *

Your Education & Occupation in two lines *

Existing symptoms and diagnoses made - write all diagnoses made separately *

1. Trouble falling asleep *

2. Feeling tense or high-strung *

3. Feeling irritable or angry *

4. Feeling down, depressed *

5. Feeling inferior to others *

6. Suicidal Thinking *

7. Stomach or bowel problems *

8. Back pain *

9. Pain in your arms, legs, or joints *

10. Headaches *

11. Chest pain or shortness of breath *

12. Dizziness *

13. Feeling tired or having low energy *

14. Trouble sleeping *

15. Shortness of breath, In the past one week *

16. Fatigue, In the past one week *

17. Lack of energy, In the past one week *

18. Swelling in ankles or legs, In the past one week *

19. Swelling in stomach area, In the past one week *

20. Cough, In the past one week *

21. Heart palpitations (fluttering), In the past one week *

22. Rapid heartbeat, In the past one week *

23. Chest pain, In the past one week *

24. Chest tightness, In the past one week *

25. Lightheadedness, In the past one week *

26. Difficulty to Walk slowly on a flat surface, In the past one week *

27. Difficulty to Walk quickly on a flat surface, In the past one week *

28. Difficulty to Walk uphill, In the past one week *

29. Difficulty to Carry things, In the past one week *

30. Difficulty to Light indoor household chores, In the past one week *

31. Difficulty to Wash or dress self, In the past one week *

32. Need help from others to put some physical efforts, In the past one week *

33. Difficulty To Think clearly, In the past one week *

34. Feeling Sad, In the past one week *

35. Feeling Worried, In the past one week *

36. Feeling Frustrated, In the past one week *

Over the LAST TWO WEEKS, how often have you been bothered by the following problems?

37. Feeling nervous, anxious or on edge *

38. Not being able to stop or control worrying *

39. Feeling down, depressed or hopeless *

40. Little interest or pleasure in doing things *

Brief Symptom Rating Scale - BSRS-5 - 0-5：Your Physical and Mental Fitness is in Good Condition 6-9：Some Emotional Distress and it is recommended that you talk to family or friends 10-14：Your Emotional Distress Makes you Uncomfortable and it is recommended that you should seek professional advice >15：Your Emotional Distress makes you Very Uncomfortable and it is recommended that you should seek professional counseling for psychiatric treatment

Somatic Symptom Scale–8 (SSS-8) - No to Minimal (0-3 points), Low(4-7 points), Medium (8-11 points), High (12-15 points), and Very High (16-32

PAH - Cardiopulmonary Symptoms (Out of 24 )Pulmonary Arterial Hypertension-Symptoms and Impact (PAH-SYMPACT) Questionnaire

PAH - Cardiovascular Symptoms - (Out of 20)Pulmonary Arterial Hypertension-Symptoms and Impact (PAH-SYMPACT) Questionnaire

PAH - Physical Impacts - (Out of 28)Pulmonary Arterial Hypertension-Symptoms and Impact (PAH-SYMPACT) Questionnaire

PAH - Cognitive / Emotional Impacts - (Out of 16)Pulmonary Arterial Hypertension-Symptoms and Impact (PAH-SYMPACT) Questionnaire

Total score is determined by adding together the scores of each of the 4 items. Scores are rated as normal (0-2), mild (3-5), moderate (6-8), and severe (9-12). Total score ≥3 for first 2 questions suggests anxiety. Total score ≥3 for last 2 questions suggests depressionPulmonary Arterial Hypertension-Symptoms and Impact (PAH-SYMPACT) Questionnaire

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