sharon

250-703-3724

Email

Facebook

 

 

Communication Questionnaire

This questionnaire is to completed upon request for a scheduled appointment. By answering the following questions I will know better how to understand the meaning of your words and the language that you use. This is not a test and there is no wrong answer. Your answers will be kept confidential. Note: All form fields must be filled in and all questions must be answered.

Please answer by clicking "yes" or "no." It is important that you answer every question. Do not analyse the questions and do not go back over your answers if a question seems similar to one you have already answered. Just answer each question with what first comes to mind upon reading the question.

Your Initials: Date:

1. Have you ever walked in your sleep during your adult life?

2. As a teenager, did you feel comfortable expressing your feelings to one or both of your parents?

3. Do you have a tendency to look directly into people's eyes and/or move closely to them when discussing an interesting subject?
4. Do you feel that most people you meet for the first time are uncritical of your appearance?
5. In a group situation with people you have just met, would you feel comfortable drawing attention to yourself by initiating a conversation?
6. Do you feel comfortable holding hands or hugging someone you are in a relationship with while other people are present?
7. When someone talks about feeling warm physically do you begin to feel warm also?
8. Do you occasionally have a tendency to tune out when someone is talking to you, and at times not even hear what the other person is saying, because you are anxious to reply with your side of it?
9. Do you feel that you learn and comprehend better by seeing and/or reading than by hearing?
10. In a new class or lecture situation, do you usually feel comfortable asking questions in front of the group?
11. When expressing your ideas, do you find it important to relate all the details leading up to the subject so the other person can understand it completely?
12. Do you enjoy relating to children?
13. Do you find it easy to be at ease and comfortable with your body movements, even when faced with unfamiliar people and circumstances?
14. Do you prefer reading fiction rather than non-fiction?
15. If you were to imagine sucking on a sour, bitter, juicy, yellow lemon would your mouth water?
16. If you feel that you deserve to be complimented for something well done, do you feel comfortable if the compliment is given to you in front of other people?
17. Do you feel that you are a good conversationalist?
18. Do you feel comfortable when complimentary attention is drawn to your physical body or appearance?
19. Have you ever awakened in the middle of the night and felt that you could not move your body and/or could not talk?
20. As a child, did you feel that you were more affected by the tone of voice of your parents than by what they actually said?
21. If someone you are associated with talks about a fear that you too have experienced, do you have a tendency to have an apprehensive or fearful feeling also?
22. If you are involved in an argument with someone, after the argument is over do you have the tendency to dwell on what you could or should have said?
23. Do you have a tendency to tune out occasionally when someone is talking to you, perhaps not even hear what was said, because your mind has drifted to something totally unrelated?
24. Do you sometimes desire to be complimented for a job well done, but feel embarrassed or uncomfortable when complimented?
25. Do you often have a fear or dread of not being able to carry on a conversation with someone you have just met?
26. Do you feel self-conscious when attention is drawn to your physical body or appearance?
27. If you have your choice, would you rather avoid being around children most of the time?
28. Do you feel that you are not relaxed or loose in body movements, especially when faced with unfamiliar people or circumstances?
29. Do you prefer reading non-fiction rather than fiction?
30. If someone describes a very bitter taste, do you have difficulty experiencing the physical feeling of it?
31. Do you generally feel that you see yourself less favourably than others see you?
32. Do you tend to feel awkward or self-conscious initiating touch (holding hands, kissing, etc.) with someone you are in a relationship with while other people are present?
33. In a new class or lecture situation do you usually feel uncomfortable asking questions in front of the group even though you desire further explanation?
34. Do you feel uneasy if someone you have just met looks you directly in the eyes when talking to you, especially if the conversation is about you?
35. In a group situation with people you have just met, would you feel uncomfortable drawing attention to yourself by initiating a conversation?
36. If you are in a relationship or are very close to someone, do you find it difficult or embarrassing to verbalize your love for him or her?