QUESTIONNAIRE

By completing this questionnaire Philip will be able to assess your situation more clearly and determine whether he can help you. Some of the questions are quite personal but it would be appreciated if you could be as honest as possible. Most of us can relate to many of the things on the form, but Philip is only really interested in something that is a real problem. For instance we all get down in the dumps from time to time, that’s normal, but if you are nearly always down in the dumps that’s not, your answer then would be yes to that

This information is treated as highly confidential, Philip is the only person to see this form. He will only contact you via email unless you request him to call you.

Email Address   Your Name   (may be left blank if you prefer) General age   Under 18 18 - 25 26 - 35 36 - 45 46 - 55 56 - 65 Over 65   Type of occupation   Student Manual White collar Professional Self employed Retired House person Between jobs Gender Male Female Do you have a good imagination? Yes No Not Sure Can you relax easily? Yes No A bit You are on your way to meet a friend, you’re not running late, but time is pressing. Someone asks you to keep an eye on a box for them (it’s not a bomb) while they pop back into their home to get their car key. Would you be likely to do this? Yes no problem Think it was a bit of a cheek but do it anyway I might do Definitely not I don’t know Were you referred to me by your Doctor? YES   No If you weren’t referred by your Doctor, can you let me know how you found out about me?           A Friend   Radio A Past Patient   Poster Yellow Pages   Brochure Newspaper   Other Marital status   Married Divorced Living with partner Single   Do you smoke?   No Yes How many a day? How long have you smoked for? (years) Weight   Under weight Normal A bit overweight Always a struggle Very overweight I am bulimic I am anorexic   Do you use recreational drugs? No Yes Everyday Everyweek Occasionally Do you drink alcohol? No Yes Everyday Everyweek Occasionally   Your sexuality Heterosexual Homosexual Bisexual Uncertain     Do you get embarrassed easily? YES NO       Do you bite your nails? YES NO       Are you sensitive and easily hurt? YES NO       Do people seem to manipulate and control you easily? YES NO       Do you find it difficult to say no? YES NO       Do you get down in the dumps easily? YES NO       Are you a compulsive sort of person? YES NO       Are you able to commit to a relationship? YES NO       Can you become very jealous in a relationship without a good cause? YES NO       Do you worry a great deal about what people may say or think about you? YES NO       If someone or something upsets you, does it tend to go over and over in your mind for days? YES NO       Do you have any significant rituals you carry out, either in your thoughts or in things you do? YES NO       Do you hold grudges? YES NO       Is being in control of situations or people VERY important to you? YES NO       Do you have repetitive dreams? YES NO       Are you able to listen to both sides of an issue and make decisions easily? YES NO       When you listen to two sides of an argument, do you tend to agree with elements of both sides and therefore find it difficult or impossible to come to a decision? YES NO       Do you get tremendous satisfaction from helping others? YES NO UNCERTAIN       Do you tend to fall in love easily? YES NO       Are you flirtatious by nature? YES NO Do you suffer from any severe phobias? No Yes How many? What are they?   Can you think of anyone you admire, famous or otherwise? No Yes Who?   what is it you admire about this person? Do you suffer with panic attacks? YES NO       Do you suffer with depression? YES NO       Do you suffer with any sexual problems? YES NO       If at a party, do you like to be centre of attention? YES No       If at a pub or party and there is a Karaoke machine would you be likely to get up and sing on your own?   Yes, I’d love it No not a chance Philip Only if I was very drunk How do you THINK your best friend would describe you (if you don't have a best friend, how do you think a best friend would describe you if you had one? Please add anything else you think will help Philip and/or a description of why you are thinking of consulting him