In the past month,do you have following feelings?
| 是Yes | 否No | |
| 休克Shock | ||
| 昏迷、晕厥、意识丧失 Fainting, syncope, unconsciousness | ||
| 想要躺下Desire to lie down | ||
| 呼吸困难Dyspnea | ||
| 虚弱Weakness | ||
| 困倦，淡漠Sleepiness, apathy | ||
| 心悸Palpitations | ||
| 烦躁不安Restlessness | ||
| 头晕Dizziness | ||
| 头痛Headaches | ||
| 皮肤潮红或苍白、出汗 Warm, clammy skin or pallor | ||
| 恶心Nausea | ||
| 腹胀Abdominal fullness | ||
| 腹鸣Borborygmi (abdominal rumbling/gurgling) | ||
| 嗳气Eructation (belching) | ||
| 呕吐Vomiting |
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