BODY PERCEPTION QUESTIONNAIRE Stephen W. Porges, Ph.D. Copyright (c) 1993 The BODY PERCEPTION QUESTIONNARIE has five sub-tests: 1) Awareness, 2) Stress Response, 3) Autonomic Nervous System Reactivity, 4) Stress Style, and 5) Health History Inventory. Each of the 122 items in the BODY PERCEPTION QUESTIONNARE are to be answered on the 5-point scoring scale described in the beginning of each sub-test. Read the instructions for each sub-test and designate your answers for each of the 122 items on the provided answer sheet. Since the BODY PERCEPTION QUESTIONNAIRE will be scored by a computer, use a #2 pencil and make heavy black marks that fill the circle completely. Do not use ink or ballpoint pens. Erase cleanly any answer you wish to change and make no stray marks on the answer sheet. I: AWARENESS Image how aware you are of your body processes. Select the answer that most accurately describes you. Rate your awareness on each of the characteristics described below using the following 5-point scale: a) never b) occasionally c) sometimes d) usually e) always During most situations I am aware of: 1. swallowing frequently 2. a ringing in my ears 3. an urge to cough to clear my throat 4. my body swaying when I am standing 5. my mouth being dry 6. how fast I am breathing 7. watering or tearing of my eyes 8. my skin itching 9. noises associated with my digestion 10. eye fatigue or pain 11. muscle tension in my back and neck 12. a swelling of my body or parts of my body 13. an urge to urinate 14. tremor in my hands 15. an urge to defecate 16. muscle tension in my arms and legs 17. a bloated feeling because of water retention 18. muscle tension in my face 19. goose bumps 20. facial twitches 21. being exhausted 22. stomach and gut pains 23. rolling or fluttering my eyes 24. stomach distension or bloatedness 25. palms sweating 26. sweat on my forehead 27. clumsiness or bumping into people 28. tremor in my lips 29. sweat in my armpits 30. sensations of prickling, tingling, or numbness in my body 31. the temperature of my face (especially my ears) 32. grinding my teeth 33. general jitteriness 34. muscle pain 35. joint pain 36. fullness of my bladder 37. my eye movements 38. back pain 39. my nose itching 40. the hair on the back of my neck "standing up" 41. needing to rest 42. difficulty in focusing 43. an urge to swallow 44. how hard my heart is beating 45. feeling constipated II: STRESS RESPONSE Imagine yourself in a very stressful situation or during periods of severe stress. Using the following 5-point scale, rate your awareness of perceived changes due to stress in each of the global response systems described below a) never b) occasionally c) sometimes d) usually e) always During stressful situations I am aware of: 46. vascular responses such as my face becoming flushed or pallid, or feeling faint. 47. body posture shifts such as being hunched over, head down, and knees locked. 48. muscle tone or tremor such as arms and legs feeling weak, hands shaking, and lips quivering. 49. breathing more rapidly and shallowly, and having difficulty in catching mybreath. 50. digestive responses including gastric distress, gas, cramps, and diarrhea. 51. difficulty in paying attention with my mind wondering or day dreaming. 52. difficulties in sensory abilities such as problems hearing, seeing, smelling, or feeling touch. 53. emotional problems such as more frequent feelings of depression, frustration, rage, or anger. 54. difficulty organizing my thoughts. 55. difficulty speaking clearly and understandably. III: 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. Using the following 5-point scale, rate yourself on each of the statements below: a) never b) occasionally c) sometimes d) usually e) always 56. I feel nauseous. 57. I have difficulty coordinating breathing and eating. 58. My nose is runny, even when I am not sick. 59. When I am eating, I have difficulty talking. 60. My heart often beats irregularly. 61. When I eat, food feels dry and sticks to my mouth and throat. 62. I have "sour" stomach. 63. I feel like vomiting. 64. I feel shortness of breath. 65. I have difficulty coordinating breathing with talking. 66. When I eat, I have difficulty coordinating swallowing, chewing, and/or sucking with breathing. 67. I have a persistent cough that interferes with my talking and eating. 68. I drool, especially when I am excited. 69. I gag from the saliva in my mouth. 70. I produce a lot of saliva even when I am not eating. 71. I have difficulty adjusting my eyes to changes in illumination. 72. I have chest pains. 73. I gag when I eat. 74. When I talk, I often feel I should cough or swallow the saliva in my mouth. 75. I am constipated. 76. I have indigestion. 77. After eating I have digestive problems. 78. I have diarrhea. 79. When I breath, I feel like I cannot get enough oxygen. 80. I have difficulty controlling my eyes. 81. I get dizzy when urinating or having a bowel movement. 82. I have trouble focusing when I go into dimly or brightly illuminated places. IV: STRESS STYLE 1 Each of us responds differently to stressful events and conditions. The Stress Style 1 Scale evaluates your style of responding to stress. Using the following 5-point scale, rate yourself on each of the statements below: a) never b) occasionally c) sometimes d) usually e) always When I am emotionally stressed because of a specific problem: 83. I approach the problem head-on. 84. I withdraw. 85. I know that things will be better later, so I wait until I feel better before acting. 86. I know that things will go better if I act immediately. 87. I feel mental tension. 88. I feel frustrated. 89. I feel insecure. 90. I feel aimless. V: STRESS STYLE 2 Each of us responds differently to stressful events and conditions. The Stress Style 2 Scale evaluates your style of responding to stress. Using the following 5-point scale, rate yourself on each of the statements below: a) never b) occasionally c) sometimes d) usually e) always When I am emotionally stressed because of a specific problem: 91. I feel dizzy. 92. I have difficulty speaking. 93. I feel a tingling in my face. 94. I feel my blood sugar drop. VI: HEALTH HISTORY INVENTORY I experience, have experienced, or have been diagnosed as having: a) never b) mild c) moderate d) severe e) debilitating 95. migraine headaches 96. gastric distress or digestive problems 97. arthritis 98. hypertension 99. hopeless unhappiness 100. clinical depression 101. bulimia 102. anorexia 103. obesity 104. asthma 105. endocrine problems (e.g., thyroid, adrenal, or gonadal hormone dysfunction) 106. eczema 107. edema 108. back problems 109. diabetes 110. epilepsy 111. cancer 112. hypoglycemia 113. heart disease 114. stroke 115. gastric & duodenal ulcers 116. psychiatric disorders 117. pneumonia 118. heart attack 119. motion sickness ***************************** the following are only for women 120. premenstrual syndrome 121. severe menstrual cramps 122. post-partum depression DEMOGRAPHICS AND HEALTH BEHAVIOR SURVEY 1. age _____ years 2. gender _____male ____ female 3. height _____ ft _____ in 4. weight ______ lbs 5. marital status ____ married ____ divorced ____ widow/widower ____ single - never married 6. education (highest amount of schooling received) ____ did not graduate high school ____ graduated high school or trade school ____ attended college or business college but did not receive a BA ____ received BA ____ post-graduate work at a University 7. employment ____ professional ____ skilled labor ____ non-skilled labor 8. Current employment status ____ working full time ____ working part time ____ not working 9. payment source for Rolfing ____ self (relatives) ____ third party ____ gratis 10. Perceived physical fitness a. very fit b. fit c. average fitness d. unfit 11. Current substance use (alcohol, drugs, cigarettes) a. no use b. slight social use c. great social use d. abuse e. severe abuse 12. Smoking (number per typical day) Now1yr ago5 yrs ago cigarettes cigars pipe 13. Alcohol servings (drinks) per typical day Now 1 yr ago5 yrs ago beer wine hard liquor 14. Are you currently taking medications for high blood pressure or heart disease? a. yes b. no If yes, what is the drug and how long have you been taking it? 15. Are you currently taking psychotropic drugs such as tranquilizers or anti-anxiety medication? a. yes b. no If yes, what is the drug and how long have you been taking it? 16. If you are currently taking any prescribed or over-the-counter medications, please list here: (list name of drug and what is being taken for) 17. Surgical history: Typeyear of surgery 18. Have you suffered any traumatic injury? a) yes b) no If yes, please describe and include date of injury. 19. Is there any strenuous physical activity on your current job? a. yes b. no 20. Do you engage in regular physical exercise for recreation off the job a. yes b. no Body Perception Questionnaire "Norms" Total Score was divided by number of questions for each subscale. Awareness Mean 3.026 Median 3.011 Std dev .797 Variance .635 Kurtosis -.634 S E Kurt .277 Skewness .195 S E Skew .139 Valid cases 308 Missing cases 7 Stress Response Mean 3.177 Median 3.100 Std dev .785 Variance .616 Kurtosis -.395 S E Kurt .275 Skewness .167 S E Skew .138 Valid cases 312 Missing cases 3 Autonomic Nervous System Reactivity Mean 1.742 Median 1.667 Std dev .468 Variance .219 Kurtosis .919 S E Kurt .278 Skewness .936 S E Skew .139 Valid cases 306 Missing cases 9 Stress Style 1 Mean 2.960 Median 3.000 Std dev .502 Variance .252 Kurtosis .209 S E Kurt .276 Skewness .213 S E Skew .138 Valid cases 310 Missing cases 5 Stress Style 2 Mean 1.808 Median 1.750 Std dev .622 Variance .387 Kurtosis 3.513 S E Kurt .277 Skewness 1.372 S E Skew .139 Valid cases 308 Missing cases 7