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476 Cahaba Park Circle
Birmingham, AL 35242
(205)980-4470 |
Full Name: |
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Session Objective: |
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INSTRUCTIONS: |
Answer each question by clicking a
 in
the box for each statement that is answered "yes". Try to give
an answer to each question to the best of your knowledge. The
default answer to each question is "no". |
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No. |
QUESTION
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Check if YES |
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1 |
Have you ever walked in your
sleep after your 18th birthday? |
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2 |
During your teenage years, did you have
any difficulty expressing your feelings to one or both of your
parents? |
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3 |
Have you ever had a very highly emotional religious
experience? |
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4 |
Do you usually look directly into a person's eyes
when you are discussing an interesting subject? |
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5 |
Do you usually move close to a person when you are
discussing an interesting subject? |
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6 |
Do you feel most people you meet for the first time
do not make any judgment of your appearance? |
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7 |
In a group of people you have just met for the first
time, would you feel uneasy about starting the conversation? |
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8 |
Do you feel at ease about holding hands or hugging
someone of the opposite sex while other people are present? |
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9 |
If someone mentions that it feels very warm in the
room you are in, do you begin to feel warm also? |
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10 |
Do you ever have times when you do not hear what
someone is saying because you are thinking about what your are going
to say? |
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11 |
Do you feel that you learn and understand better by
seeing and reading than by hearing? |
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12 |
If you attend a new class or lecture, do you feel at
ease about asking questions in front of the group? |
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13 |
When expressing your ideas, do you find it important
to tell all the details leading up to the subject so the other
person can understand it completely? |
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14 |
Do you enjoy relating to children? |
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15 |
Are you at ease and comfortable about your body
movements even when you are with unfamiliar people? |
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16 |
Do you prefer reading material based on true facts
instead of material that comes form someone's imagination? |
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17 |
If you see someone sucking on a sour lemon, does it
cause your mouth to water? |
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18 |
If you were to imagine someone sucking on a sour
lemon, would it cause your mouth to water? |
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19 |
If you have performed a task very successfully, would
you feel comfortable if you were complimented in front of other
people? |
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20 |
Do you feel comfortable if someone compliments you
about your physical body or your appearance? |
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21 |
Have you ever awakened in the middle of the night and
felt that you could not move your body and/or could not talk? |
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22 |
As a child, did you feel you were more affected by
the tone of voice of your parents than by what they actually said? |
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23 |
If someone talks about a fear that you have
experienced, does it cause you to feel apprehensive or fearful? |
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24 |
If you have had an argument with someone, after it is
over, do you have a tendency to think about what you could have or
should have said? |
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25 |
Do you occasionally not hear what someone has said to
you because your mind is on something completely different? |
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26 |
Do you sometimes desire to be complimented for an
accomplishment, but feel embarrassed or uncomfortable when
complimented? |
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27 |
Do you often have a fear of not being able to carry
on a conversation with someone you have just met? |
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28 |
Do you feel self-conscious if someone mentions
something about your physical body or appearance? |
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29 |
If you have a choice, would you prefer not being
around children most of the time? |
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30 |
Do you feel a little tense and anxious about body
movements around unfamiliar people? |
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31 |
Do you prefer reading material that comes from
someone's imagination instead of material based upon true facts? |
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32 |
Do you feel that getting emotional about religion is
something you would want to avoid? |
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33 |
If someone describes a bitter taste, do you have
difficulty experiencing the physical feeling of it? |
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34 |
If someone describes a beautiful scene, such as a
sailboat floating on a peaceful lake, do you have difficulty
visualizing the scene? |
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35 |
Do you feel that your own opinion of yourself is not
as good as other people's opinion about you? |
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36 |
Do you feel self-conscious about reaching out and
kissing or putting your arms around a person you are dating or are
married to if other people are present? |
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37 |
In a new class or lecture situation, do you usually
feel uneasy asking questions even though you desire more
explanation? |
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38 |
Do you feel uneasy if a new acquaintance looks
directly in your eyes when talking to you? |
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39 |
In a group situation with people you have just met,
would you feel uncomfortable about starting a conversation? |
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40 |
If you are with a person you love, do you find it
difficult to tell him/her about your feelings of love? |
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- A Day Spa, 476 Cahaba Park
Circle, Birmingham, AL 35242