Research Tool

PART I. RESPONDENT’S PROFILE

Please supply/put a check mark on the following boxes related to your profile.

NAME (Optional)

AGE (Years) GENDER EDUCATIONAL ATTAINMENT

18 – 27 Male Elementary Graduate Others _______

28 – 37 Female High School Undergraduate
38 – 47 High School Graduate
48 – 57 College Undergraduate
58 and above College Graduate
With Master’s degree units
Master’s degree holder
With PhD units
PhD holder

PART II. THE FEAR QUESTIONNAIRE

Put a check mark on the box identifying your best response
How much do you avoid each of the situations listed below because of fear or of other unpleasant things?

0 1 2 3 4 5 6 7 8

Would not Slightly Definitely Markedly Always

avoid it avoid it avoid it avoid it avoid it

1 Main phobia you want treated (Describe in your

own words)

2 Injections or minor surgery

3 Eating or drinking with other people
4 Hospitals
5 Traveling alone or by bus
6 Walking alone in busy streets
7 Being watched or stared at
8 Going into crowded shops
9 Talking to people in authority
10 Sight of blood
11 Being criticized
12 Going alone far from home
13 Thought of injury or illness
14 Speaking or acting to an audience
15 Large open spaces
16 Going to the dentist
17 Other situations (Describe)

Put a check mark on the box identifying your best response

How much are you troubled by each problem listed below?

0 1 2 3 4 5 6 7 8

Hardly at Slightly Definitely Markedly Very severely

troublesome troublesome troublesome troublesome
all

18 Feeling miserable or depressed

19 Feeling irritable or angry
20 Feeling tense or panicky
21 Upsetting thoughts coming into your mind
22 Feeling you or your surroundings are strange or
unreal
23 Other feelings (Describe)

Please circle one number between 0 and 8

How would you rate the present state of your phobic symptoms on the scale below?

0 1 2 3 4 5 6 7 8

No phobias
No Slightly Definitely Markedly Very severely
prsent disturbing/not
troublesome disturbing/disa
troublesome disturbing/disa
troublesome disturbing/disa
troublesome
phobias really disabling bling bling bling
prsent

PART III. IMPLICATIONS OF PHOBIA ON YOUR HELP SEEKING ACTIVITIES

Put a check mark on the box identifying your best response
What are the implications of your specific phobia on your help – seeking activities?
Always Never

HELP SEEKING ACTIVITIES

MEDICAL
(e.g. Seeking care from community agencies)

ALTERNATIVE OR TRADITIONAL HEALING

(e.g. Seeking care from lay people or traditional healers)
SPIRITUAL
(e.g.)