Misophonia Part A and B Misophonia Part A and B"*" indicates required fieldsName*Birthday* MM slash DD slash YYYY Form Completed By: Self Parent OtherLocation for which you are filling the formChoose LocationCalgaryHigh RiverLethbridgeGrande PrairieFor ParentFor Other MisophoniaPart ARATING SCALE: 0 = Not at all 1 = A little of the time 2 = A good deal of the time 3 = Almost all the timeMy sound issues make me unhappy* 0 1 2 3My sound issues create problems for me.* 0 1 2 3My sound issues have made me feel angry.* 0 1 2 3I feel that no one understands my problems with certain sounds.* 0 1 2 3My sound issues do not seem to have a known cause.* 0 1 2 3My sound issues make me feel helpless.* 0 1 2 3My sound issues make me feel isolated.* 0 1 2 3My sound issues interfere with my social life.* 0 1 2 3My sound issues create problems for me in groups.* 0 1 2 3My sound issues negatively affect my work life.* 0 1 2 3My sound issues make me feel frustrated.* 0 1 2 3My sound issues impact my entire life negatively* 0 1 2 3My sound issues make me feel guilty.* 0 1 2 3My sound issues have been classified as ‘crazy.’* 0 1 2 3I feel that no one can help me with my sound issues.* 0 1 2 3My sound issues make me feel hopeless.* 0 1 2 3I feel that my sound issues will only get worse with time.* 0 1 2 3My sound issues impact my family relationships.* 0 1 2 3My sound issues have affected my ability to be with other people.* 0 1 2 3My sound issues have not be recognized as legitimate.* 0 1 2 3I am worried that my whole life will be affected by sound issues.* 0 1 2 3 Misophonia Part BHow much of your time is occupied by bothersome/trigger sounds?*Select your choice0 = None1 = Mild, less than 1 hr/day, or occasionally (thoughts about) sounds (no more than 5 times a day)2 = Moderate, 1 to 3 hrs/day, or frequent (thoughts about) sounds (no more than 8 times a day, most of the hours are unaffected3 = Severe, greater than 3 hrs and up to 8 hrs/day or very frequent (thoughts about) sounds4 = Extreme greater than 8 hrs/day or near constant (thoughts about) sounds(How frequently do the thoughts about the trigger sounds occur?)How much do these trigger sounds interfere with your social, work or role functioning?*Select your choice0 = None1 = Mild slight interference with social / occupational / school activities, but overall performance not impaired2 = Moderate definite interference with social or occupational performance, but still manageable3 = Severe causes substantial impairment in social or occupational performance4 = Extreme incapacitating(Is there anything that you don’t do because of them? If currently not working determine how much performance would be affected if you were employed.)How much distress do the trigger sounds cause you?*Select your choice0 = None1= Mild occasional irritation/distress2 = Moderate disturbing irritation/anger/disgust, but still manageable3 = Severe very disturbing irritation/anger/disgust4 = Extreme near constant and disturbing anger/disgust(In most cases, distress is equated with irritation, anger or disgust. Only rate the emotion that seems triggered by bothersome sounds, not generalized irritation or irritation associated with other conditions.)How much effort do you make to resist the (thoughts about the) trigger sounds?*Select your choice0 = Makes an effort to always resist, (or symptoms so minimal, doesn’t need to actively resist)1 = Tries to resist most of the time2 = Makes some effort to resist3 = Yields to all (thoughts about) trigger sounds without attempting to control them, but does so with some reluctance4 = Completely and willing yields to all obsessions(How often do you try to disregard or turn your attention away from these sounds? Only rate effort made to resist, not success or failure in actually controlling the thought or sound.)How much control do you you have over your thoughts about the tigger sounds? How successful are you in stopping or diverting your thinking about the trigger sounds? Can you dismiss them?*Select your choice0 = Complete control1 = Much control usually able to stop or divert thoughts about trigger sounds2 = Moderate control sometimes able to stop or divert thoughts about trigger sounds3 = Little control rarely successful in stopping or dismissing thoughts about trigger sounds, can only divert attention with difficult4 = No control experience thoughts as completely involuntary, rarely able to alter thinking about trigger soundsHave you been avoiding doing anything, going any place, or being with anyone because of your reactions to trigger sounds?*Select your choice0 = No deliberate avoidance1 = Mild minimal avoidance, Less than an hr/day or occasional avoidance2= Moderate some avoidance. 1 to 3 hr/day or frequent avoidance3 = Severe much avoidance. Greater than 3 up to 8 hr/day. Very frequent avoidance4 = Extreme very extensive avoidance. Greater than 8 hr/day. Doing almost everything you can to avoid triggering symptoms(How much do you avoid, for example, by using other loud sounds, such as music?)Finally: What would be the worst thing that could happen (to you) if you were not able to avoid the misophonic sounds? Please describe below:*Any Additional Comments:
