Body Perceptions Questionnaire Short Form

Body Awareness

Please rate your awareness on each of the characteristics described below. Select the answer that most accurately describes you.

Swallowing frequently*

Never

Always

An urge to cough to clear my throat*

Never

Always

My mouth being dry*

Never

Always

How fast I am breathing*

Never

Always

Watering or tearing of my eyes*

Never

Always

Noises associated with my digestion*

Never

Always

A swelling of my body or parts of my body*

Never

Always

An urge to defecate*

Never

Always

Muscle tension in my arms and legs*

Never

Always

A bloated feeling because of water retention*

Never

Always

Muscle tension in my face*

Never

Always

Goose bumps*

Never

Always

Stomach and gut pains*

Never

Always

Stomach distension or bloatedness*

Never

Always

Palms sweating*

Never

Always

Sweat on my forehead*

Never

Always

Tremor in my lips*

Never

Always

Sweat in my armpits*

Never

Always

The temperature of my face (especially my ears)*

Never

Always

Grinding my teeth*

Never

Always

General jitteriness*

Never

Always

The hair on the back of my neck “standing up”*

Never

Always

Difficulty in focusing*

Never

Always

An urge to swallow*

Never

Always

How hard my heart is beating*

Never

Always

Feeling constipated*

Never

Always

Autonomic Nervous System Reactivity

The autonomic nervous system is the part of your nervous system that controls your cardiovascular, respiratory, digestive, and temperature regulation systems. It is also involved in the experience and expression of emotions. The autonomic nervous system functions differently among people. This scale has been developed to measure how your autonomic nervous system reacts. In your daily life, how often are you aware of the following sensations? Please rate yourself on each of the statements below:

I have difficulty coordinating breathing and eating.*

Never

Always

When I am eating, I have difficulty talking.*

Never

Always

My heart often beats irregularly.*

Never

Always

When I eat, food feels dry and sticks to my mouth and throat.*

Never

Always

I feel shortness of breath.*

Never

Always

I have difficulty coordinating breathing with talking.*

Never

Always

When I eat, I have difficulty swallowing, chewing, and/or sucking with breathing.*

Never

Always

I have a persistent cough that interferes with my talking and eating.*

Never

Always

I gag from the saliva in my mouth.*

Never

Always

I have chest pains.*

Never

Always

I gag when I eat.*

Never

Always

When I talk, I often feel I should cough or swallow the saliva in my mouth.*

Never

Always

When I breathe, I feel like I cannot get enough oxygen.*

Never

Always

I have difficulty controlling my eyes.*

Never

Always

I feel like vomiting.*

Never

Always

I have 'sour' stomach.*

Never

Always

I am constipated.*

Never

Always

I have indigestion.*

Never

Always

After eating I have digestive problems.*

Never

Always

I have diarrhea.*

Never

Always

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