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Arousal
Name
*
Contact Number
*
Email Address
*
Street Address
Apartment, suite, etc
City
State/Province
ZIP / Postal Code
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Australia
Aruba
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
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Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cabo Verde
Cayman Islands
Central African Republic
Chad
Chile
China, People's Republic of
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
France, Metropolitan
French Guiana
French Polynesia
French South Territories
Gabon
Gambia
Georgia
Germany
Guernsey
Ghana
Gibraltar
Greece
Greenland
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Guam
Guatemala
Guinea
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Guyana
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Honduras
Hong Kong
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Date of Birth
*
1. How much you feel - Heart racing, pounding or beating irregularly.
*
Choose Out of 5 Alternatives Here, Carefully
Extremely / Very Much
Much
To Some Extent
Very Less
Not At All
2. How much you feel - Shortness of breath or labored breathing.
*
Choose Out of 5 Alternatives Here, Carefully
Extremely / Very Much
Much
To Some Extent
Very Less
Not At All
3. How much you feel - A tight, tense feeling in your muscles.
*
Choose Out of 5 Alternatives Here, Carefully
Extremely / Very Much
Much
To Some Extent
Very Less
Not At All
4. How much you feel - Cold feeling in your hands, feet or your body in general.
*
Choose Out of 5 Alternatives Here, Carefully
Extremely / Very Much
Much
To Some Extent
Very Less
Not At All
5. How much you feel - Have stomach upset (knot or nervous feeling in stomach, heartburn, nausea, gas etc.).
*
Choose Out of 5 Alternatives Here, Carefully
Extremely / Very Much
Much
To Some Extent
Very Less
Not At All
6. How much you feel - Perspiration in palms of your hands or other parts of your body.
*
Choose Out of 5 Alternatives Here, Carefully
Extremely / Very Much
Much
To Some Extent
Very Less
Not At All
7. How much you feel - Dry feeling in mouth or throat.
*
Choose Out of 5 Alternatives Here, Carefully
Extremely / Very Much
Much
To Some Extent
Very Less
Not At All
8. How much you feel - Worry about falling asleep.
*
Choose Out of 5 Alternatives Here, Carefully
Extremely / Very Much
Much
To Some Extent
Very Less
Not At All
9. How much you feel - Review or ponder events of the day.
*
Choose Out of 5 Alternatives Here, Carefully
Extremely / Very Much
Much
To Some Extent
Very Less
Not At All
10. How much you feel - Depressing or anxious thoughts.
*
Choose Out of 5 Alternatives Here, Carefully
Extremely / Very Much
Much
To Some Extent
Very Less
Not At All
11. How much you feel - Worry about problems other than sleep.
*
Choose Out of 5 Alternatives Here, Carefully
Extremely / Very Much
Much
To Some Extent
Very Less
Not At All
12. How much you feel - Being mentally alert, active.
*
Choose Out of 5 Alternatives Here, Carefully
Extremely / Very Much
Much
To Some Extent
Very Less
Not At All
13. How much you feel - Can't shut off your thoughts.
*
Choose Out of 5 Alternatives Here, Carefully
Extremely / Very Much
Much
To Some Extent
Very Less
Not At All
14. How much you feel - Thoughts keep running through your head.
*
Choose Out of 5 Alternatives Here, Carefully
Extremely / Very Much
Much
To Some Extent
Very Less
Not At All
15. How much you feel - A jittery, nervous feeling in your body.
*
Choose Out of 5 Alternatives Here, Carefully
Extremely / Very Much
Much
To Some Extent
Very Less
Not At All
16. How much you feel - Being distracted by sounds, noise in the environment (e.g. ticking of clock, house noises, traffic).
*
Choose Out of 5 Alternatives Here, Carefully
Extremely / Very Much
Much
To Some Extent
Very Less
Not At All
Pre-Sleep Arousal Scale (Markus Jansson-Fröjmark and Annika Norell-Clarke 2012) - Somatic Arousal OUT OF 35
Pre-Sleep Arousal Scale (Markus Jansson-Fröjmark and Annika Norell-Clarke 2012) - Cognitive Arousal OUT OF 25
Pre-Sleep Arousal Scale (Markus Jansson-Fröjmark and Annika Norell-Clarke 2012) - Meta Cognitive Arousal OUT OF 15
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