Misophonia Part C and D Misophonia Part C and D"*" indicates required fieldsPlease only select ONE statement in each category that best describes what you experience for emotional response and physical sensation. “Trigger sound” refers to a sound that causes issues for you.Full NameDate Of Birth MM slash DD slash YYYY Location for which you are filling the form*CalgaryHigh RiverLethbridgeGrande PrairieForm completed by Self Parent OtherEmotional Response*Select your choice(0) I hear a known trigger sound but feel no discomfort(1) I am aware of the presence of a known trigger person but feel no, or minimal, anticipatory anxiety.(2) Known trigger sounds elicit minimal psychic discomfort, irritation or annoyance. No symptoms of panic or fight or flight response.(3) I feel increasing levels of psychic discomfort but do not engage in any physical response. I may be hyper vigilant to audio-visual stimuli.(4) I engage in a minimal physical response – non-confrontational coping behaviors, such as asking the trigger person to stop making the noise, discreetly covering one ear, or by calmly moving away from the noise. No panic or fight or flight symptoms exhibited.(5) I adopt more confrontational coping mechanisms, such as overtly covering my ears, mimicking the trigger person, make repeated sounds, or display overt irritation.(6) I experience substantial psychic discomfort. Symptoms of panic and a fight or flight response begin to engage.(7) I experience substantial psychic discomfort. Increasing use (louder, more frequent) use of confrontational coping mechanisms. I may re-imagine the trigger sound and visual cues over and over again, sometimes for weeks, months or even years after the event.(8) I experience substantial psychic discomfort and some violence thoughts.(9) Panic/rage reaction in full swing. Conscious decision not to use violence on trigger person. Actual flight from vicinity of noise and/or use of physical violence on an inanimate object. Panic, anger or severe irritation may be manifest in my demeanor.10) Actual use of physical violence on a person or animal (i.e., a household pet). Violence may be inflicted on self (self-harming).Some unpleasant sounds make me instantly angry.*Select your choiceA. Strongly DesagreeB. DesagreeC. Neither Agree Nor DisagreeD. AgreeE. Strongly AgreeRate the following statements based on how much you agree with them on a scale of strongly disagree to strongly agree.I find some sounds made by the human body unbearable.*Select your choiceA. Strongly DesagreeB. DesagreeC. Neither Agree Nor DisagreeD. AgreeE. Strongly AgreeI start feeling anger the moment I see a thing/animal/person that might make an unpleasant sound at any time.*Select your choiceA. Strongly DesagreeB. DesagreeC. Neither Agree Nor DisagreeD. AgreeE. Strongly AgreeWhen I hear unpleasant sounds, I start sensing emotions in my body (e.g., I sweat, feel pain, feel pressure, my muscles tense).*Select your choiceA. Strongly DesagreeB. DesagreeC. Neither Agree Nor DisagreeD. AgreeE. Strongly AgreeUnpleasant sounds make me feel overwhelmed.*Select your choiceA. Strongly DesagreeB. DesagreeC. Neither Agree Nor DisagreeD. AgreeE. Strongly AgreeI become anxious at the mere thought of an unpleasant sound*Select your choiceA. Strongly DesagreeB. DesagreeC. Neither Agree Nor DisagreeD. AgreeE. Strongly AgreeSome sounds bother me so much that I have difficulty controlling my emotions.*Select your choiceA. Strongly DesagreeB. DesagreeC. Neither Agree Nor DisagreeD. AgreeE. Strongly AgreeI put a lot of effort into controlling emotions when I hear an unpleasant sound.*Select your choiceA. Strongly DesagreeB. DesagreeC. Neither Agree Nor DisagreeD. AgreeE. Strongly AgreeI believe that my reactions to sounds are exaggerated but I can’t get rid of them*Select your choiceA. Strongly DesagreeB. DesagreeC. Neither Agree Nor DisagreeD. AgreeE. Strongly AgreeIf I can, I avoid meeting with certain people because of the sounds they make.*Select your choiceA. Strongly DesagreeB. DesagreeC. Neither Agree Nor DisagreeD. AgreeE. Strongly AgreeI feel that my mental state worsens if I cannot leave a place where there’s an unpleasant sound.*Select your choiceA. Strongly DesagreeB. DesagreeC. Neither Agree Nor DisagreeD. AgreeE. Strongly AgreeI often think about how to drown out unpleasant sounds.*Select your choiceA. Strongly DesagreeB. DesagreeC. Neither Agree Nor DisagreeD. AgreeE. Strongly AgreeI am scared that unpleasant sounds may impact my future.*Select your choiceA. Strongly DesagreeB. DesagreeC. Neither Agree Nor DisagreeD. AgreeE. Strongly AgreeWhen meeting with other people, I am sometimes irritated because of unpleasant sounds that are present.*Select your choiceA. Strongly DesagreeB. DesagreeC. Neither Agree Nor DisagreeD. AgreeE. Strongly AgreeAny Additional Comments: