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    BPQ Questionnaire PDF

    Uploaded by

    Aymen Dabboussi

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    BPQ Questionnaire PDF

    Uploaded by

    Aymen Dabboussi
    286 views4 pages

    Original Title

    BPQ-questionnaire.pdf

    Copyright

    © © All Rights Reserved

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    PDF, TXT or read online from Scribd

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    Copyright:

    © All Rights Reserved
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    286 views4 pages

    BPQ Questionnaire PDF

    Uploaded by

    Aymen Dabboussi

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
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    The document appears to be assessing body awareness and autonomic nervous system reactivity through a questionnaire.

    The Body Perception Questionnaire is assessing an individual's awareness of various internal bodily sensations and functions.

    The autonomic nervous system is the part of the nervous system that controls cardiovascular, respiratory, digestive, and temperature regulation systems and is also involved in the experience and expression of emotions.

    1

    Body Perception Questionnaire Short Form


    Stephen W. Porges © 1993, 2015

    I. Body Awareness

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

    During most situations I am aware of:

    Never Occasionally Sometimes Usually Always

    1 Swallowing frequently o o o o o

    An urge to cough to
    2
    clear my throat
    o o o o o

    3 My mouth being dry o o o o o

    4 How fast I am breathing o o o o o

    Watering or tearing of
    5
    my eyes o o o o o

    Never Occasionally Sometimes Usually Always

    Noises associated with


    6
    my digestion
    o o o o o

    A swelling of my body or
    7
    parts of my body o o o o o

    8 An urge to defecate o o o o o

    Muscle tension in my
    9
    arms and legs
    o o o o o
    A bloated feeling
    10 because of water o o o o o
    retention
    Muscle tension in my
    11
    face o o o o o
    Never Occasionally Sometimes Usually Always
    2

    Never Occasionally Sometimes Usually Always

    12 Goose bumps o o o o o

    13 Stomach and gut pains o o o o o

    Stomach distension or
    14
    bloatedness o o o o o

    15 Palms sweating o o o o o

    16 Sweat on my forehead o o o o o

    17 Tremor in my lips o o o o o

    18 Sweat in my armpits o o o o o

    The temperature of my
    19
    face (especially my ears)
    o o o o o
    Never Occasionally Sometimes Usually Always

    20 Grinding my teeth o o o o o

    21 General jitteriness o o o o o

    The hair on the back of


    22
    my neck "standing up"
    o o o o o

    23 Difficulty in focusing o o o o o

    24 An urge to swallow o o o o o

    How hard my heart is


    25
    beating o o o o o

    26 Feeling constipated o o o o o
    Never Occasionally Sometimes Usually Always
    3

    II. 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.

    Please rate yourself on each of the statements below:

    Never Occasionally Sometimes Usually Always


    I have difficulty
    27 coordinating breathing o o o o o
    and eating.
    When I am eating, I
    28
    have difficulty talking. o o o o o

    My heart often beats


    29
    irregularly.
    o o o o o
    When I eat, food feels
    30 dry and sticks to my o o o o o
    mouth and throat.
    I feel shortness of
    31
    breath. o o o o o

    Never Occasionally Sometimes Usually Always


    I have difficulty
    32 coordinating breathing o o o o o
    with talking.
    When I eat, I have
    difficulty coordinating
    33 swallowing, chewing, o o o o o
    and/or sucking with
    breathing.
    I have a persistent
    cough that interferes
    34
    with my talking and
    o o o o o
    eating.
    I gag from the saliva in
    35
    my mouth. o o o o o

    36 I have chest pains. o o o o o

    Never Occasionally Sometimes Usually Always


    4

    Never Occasionally Sometimes Usually Always

    37 I gag when I eat. o o o o o

    When I talk, I often feel I


    38 should cough or swallow o o o o o
    the saliva in my mouth.

    When I breathe, I feel


    39 like I cannot get enough o o o o o
    oxygen.
    I have difficulty
    40
    controlling my eyes. o o o o o

    41 I feel like vomiting o o o o o


    Never Occasionally Sometimes Usually Always

    42 I have 'sour' stomach. o o o o o

    43 I am constipated o o o o o

    44 I have indigestion. o o o o o

    After eating I have


    45
    digestive problems. o o o o o

    46 I have diarrhea o o o o o

    Never Occasionally Sometimes Usually Always

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