Fear of Vomiting Questionnaire (FOV)

Fear of Vomiting Questionnaire (FOV) is a self report questionnaire devised by David Veale which is used for clinicians to provide a comprehensive assessment of the beliefs‚ safety and avoidance behaviours‚ degree of handicap associated with SPOV caused and avoidance behaviours adopted. Some of the items are adapted from standard questionnaires (e.g. assessment of safety seeking behaviours in panic). Some of the items may be used after treatment to assess outcome. The questionnaire was used in the published surveys of SPOV.
Download the FOV and the FOV follow up
Veale‚ D. and Lambrou‚ C. (2006). The psychopathology of vomit phobia. Behavioural and Cognitive Psychotherapy‚34 (2) 139-150
Fear of Vomiting Questionnaire
Name: ___________________________ Date: ___________________________
Please complete this questionnaire as best as you can to help us understand as much as possible about your fear.
 
1) How old were you when you first became aware of your fear of vomiting? _______
2) How old were you when your fear of vomiting became a significant problem? ____
3) Since your fear of vomiting became a problem‚ what course has it taken? Please circle the letter next to the statement that best describes your problem.
a) It has been continuous but overall the problem has become worse
b) It has been continuous but overall the problem has stayed much the same
c) It has been continuous but overall the problem has got better
d) It has varied. Although it has never gone away‚ there have been times when the problem has been much worse and times when it has been much better
e) It has varied. At times it has not been a problem at all and at other times it has been worse
4) How old were you when you first sought help for your fear of vomiting? ________
5) How old are you now? _____________
6) For how many years have you NOT vomited? _____________
7) Sex: (Please circle)     Female / Male
8) Marital Status: (Please circle) Single / Married or co-habiting / Divorced / Widowed
9) Employment Status: (Please circle) Unemployed / Long-Term Sick Leave / Student Employed or self Employed / Homemaker / Other ____________
10) Please read all the options below and circle the letter that best describes your current situation
a) I only fear myself vomiting (not others)
b) My main fear is of myself vomiting but I have some fear of others vomiting
c) I fear equally myself and others vomiting
d) My main fear is of others vomiting but I have some fear of myself vomiting
e) I only fear others vomiting (not myself)
11) If you fear others vomiting‚ please circle one or more reasons for this fear.
Please go to question 12 if you only fear yourself vomiting and not others.
a) I may catch something from the person vomiting and then vomit myself
b) It makes me think I could vomit one day
c) It reminds me of past experiences of vomiting
d) Another reason ( Please specify) ____________________________
12) Please read all the options below and circle the letter attached to the statement that best describes your fear of vomiting whether you are in public or alone
a) I fear myself vomiting in public or social situations only
b) My main fear is of myself vomiting in public but I have some fear of vomiting alone
c) I fear myself vomiting whether it is in public/social situations or alone
d) My main fear is vomiting alone but I also have some fear of vomiting in public or social situations
e) I fear myself vomiting only when I am alone
13) Have you ever had any experiences of vomiting in your life? Yes No
If yes‚ please list your past experience(s) of yourself vomiting (not retching) from the earliest age you can remember up to the present day. Please use an additional sheet if you need the space.
How old were you?
How distressing is the memory of the experiences on a scale of 0-10 (0 is not at all distressing and 10 is severe)?
What were the circumstances or reasons for vomiting (e.g. infection‚ being drunk‚ pregnancy‚ travel sickness‚ food)?
Did you experience any bad consequences from vomiting (e.g. reaction of a relative)? Does the episode carry other associations from that time (e.g. other bad
events happening in your life)? Do you have a sense that something bad happened (e.g. you nearly died)?
14) Have you ever had any experience of feeling nauseous or retching (but not vomiting) and feeling panicky in your life? Yes No
If yes‚ please list your past experience(s) of feeling nauseous/retching from the earliest age you can remember up to the present day. Please use an additional sheet if you need the space.
How old were you?
How distressing is the memory of the experience on a scale of 0-10 (0 is not at all distressing and 10 is severe)?
What were the circumstances or reasons for you feeling nauseous?
Did you have a panic attack at the same time or severe anxiety which came on rapidly?
Were there any bad consequences from feeling sick and panicky (e.g. reaction of a relative) or other associations at the time (e.g. other bad events happening in your life?) or a sense that something bad nearly happened because of this experience?
15) Have you had any bad experiences of vomit or of other people vomiting in front of you or on you? Yes No
If yes‚ please list your past experience(s) of vomit or of others vomiting from the earliest age you can remember. Please use an additional sheet if you need the space.
How old were you?
How distressing is the memory of the experience on a scale of 0-10 (0 is not at all distressing and 10 is severe)?
What were the circumstances surrounding your past experience of vomit or of others vomiting?
Were there any bad consequences of the other person vomiting (e.g. reaction of a relative) or other associations at the time (e.g. other bad events happening in your life?) or a sense that something bad nearly happened because of this experience?
16) How often‚ on average‚ do you think a woman vomits from an infection or food-poisoning in your country?
Once every _______month(s) OR ________ year(s)
17) How often in the future do you think you will vomit from an infection or food-poisoning?
Once every _________ month(s) OR _________ year(s)
18) How long on average‚ do you think an episode of vomiting from an infection or food-poisoning would last for in an average woman?
_________ Minutes OR _________ hours OR _________ days
19) If you were to suffer an episode of vomiting caused by infection or food-poisoning how long do you think it would last for?
_________ Minutes OR _________ hours OR _________ days
20) What proportion of women do you think vomit during their first pregnancy?
________%
21) What proportion of women do you think vomit during the second or third pregnancy?
________%
22) What proportion of women do you think vomit after a general an aesthetic?
________%
23) What proportion of women do you think vomit during foreign travel in a third world or emerging country (e.g. India)?
________%
24) What goes through your mind when you feel nauseous?
a. Please indicate how often you experience each of the thoughts in the following list: rate each thought from 1 to 5 using the scale below; put your rating in the column marked ‘OCCURENCE’.
1-‎-‎-‎-‎-‎-‎-‎-‎-‎-‎-‎-‎-‎-‎-‎-2-‎-‎-‎-‎-‎-‎-‎-‎-‎-‎-‎-‎-‎-‎-‎-‎-3-‎-‎-‎-‎-‎-‎-‎-‎-‎-‎-‎-‎-‎-‎-‎-‎-4-‎-‎-‎-‎-‎-‎-‎-‎-‎-‎-‎-‎-‎-‎-‎-‎-‎-5
1= Thought never occurs 2= Thought rarely occurs 3=Thought occurs during half of the times when I feel nauseous 4 = Thought usually occurs 5= Thought always occurs when I feel nauseous
b. When you feel sick‚ how much do you believe each of the thoughts below to be true? Please rate each thought from 0 to 100 using the scale below; put your rating in the ‘BELIEF’ column.
0-‎-‎-‎-‎-‎-‎-‎-‎-10-‎-‎-‎-‎-‎-‎-‎-‎-20-‎-‎-‎-‎-‎-‎-‎-‎-30-‎-‎-‎-‎-‎-‎-‎-‎-40-‎-‎-‎-‎-‎-‎-‎-‎-50-‎-‎-‎-‎-‎-‎-‎-‎-60-‎-‎-‎-‎-‎-‎-‎-‎-70-‎-‎-‎-‎-‎-‎-‎-‎-80-‎-‎-‎-‎-‎-‎-‎-‎-90-‎-‎-‎-‎-‎-‎-‎-‎-100
0=I do not believe this Thought at all‚ 20= I am slightly convinced this thought is true‚ 50= I am half convinced this thought is true‚ 70= I am very convinced this thought is true‚ 100= I am completely convinced this thought is true
 
thoughts
Occurrence
(Please rate 1-5)
Belief
(Please rate 0-100)
I am going to vomit
 
 
I am going to pass out
 
 
I will choke to death
 
 
I am going to act foolishly
 
 
I will lose control
 
 
I will go crazy
 
 
I am going to babble or talk strangely
 
 
I will be paralysed with fear
 
 
I am going to die
 
 
I am seriously ill
 
 
Other – please state
 
 
 
 
 
 
25) If you thought you might “lose control“‚ can you describe what you think will happen‚ from the perspective of what others would see and from your own perspective of what you would feel?
…………………………………………………………………………………………
…………………………………………………………………………………………
26) How many days a week over the past week have you felt nauseous [at least some of the time]?
________ Days during the past week
27) What do you believe is the cause of your nausea?
Please rate the strength of your belief for each of these causes on a scale between 0 -100% where 0% is not at all convinced and 100% is totally convinced.
 
Cause
Rating 0-100%
 
Anxiety
 
Irritable Bowel Syndrome
 
Migraine
 
Balance Lean Problem??
 
Cancer
 
Ulcer or stomach inflammation
 
Unknown physical cause
 
Other (Please specify)_____________________
 
28) Do you do any of the following when you feel sick? Please circle one for each item.
Try to think about other things
Never
Sometimes
Often
Always
Hold on to something tightly
Never
Sometimes
Often
Always
Hold on to or lean on someone
Never
Sometimes
Often
Always
Sit down
Never
Sometimes
Often
Always
Keep still
Never
Sometimes
Often
Always
Move very slowly
Never
Sometimes
Often
Always
Look for an escape route
Never
Sometimes
Often
Always
Make myself do more physical exercise
Never
Sometimes
Often
Always
Focus attention on how I feel physically
Never
Sometimes
Often
Always
Try to keep control of my mind
Never
Sometimes
Often
Always
Try to keep tight control over my vomiting
Never
Sometimes
Often
Always
Talk more
Never
Sometimes
Often
Always
Ask people around for help
Never
Sometimes
Often
Always
Change my breathing
Never
Sometimes
Often
Always
Physically check my body
Never
Sometimes
Often
Always
Eat something
Never
Sometimes
Often
Always
Go to bed
Never
Sometimes
Often
Always
Suck on ice
Never
Sometimes
Often
Always
Read
Never
Sometimes
Often
Always
Suck antacids/mints
Never
Sometimes
Often
Always
Recite a phrase
Never
Sometimes
Often
Always
Reassure myself no-one will vomit (inc me)
Never
Sometimes
Often
Always
Seek reassurance from others
Never
Sometimes
Often
Always
Take medication
Never
Sometimes
Often
Always
What kind of medication do you currently take‚ how often do you take it and at what dose?
_________________________________________________________________________________
29) What else do you do if you think you are going to vomit? (Please circle)
1______________________________
Never
Sometimes
Often
Always
2______________________________
Never
Sometimes
Often
Always
3______________________________
Never
Sometimes
Often
Always
4______________________________
Never
Sometimes
Often
Always
30) Please read through the list of consequences that you think might occur after vomiting in the first column of the table.
a) In the second column please rate the likelihood of the consequence occurring if you were to vomit‚ on a scale between 0 and 100 using the scale below as a guide.
0-‎-‎-‎-‎-‎-‎-‎-‎-10-‎-‎-‎-‎-‎-‎-‎-‎-20-‎-‎-‎-‎-‎-‎-‎-‎-30-‎-‎-‎-‎-‎-‎-‎-‎-40-‎-‎-‎-‎-‎-‎-‎-‎-50-‎-‎-‎-‎-‎-‎-‎-‎-60-‎-‎-‎-‎-‎-‎-‎-‎-70-‎-‎-‎-‎-‎-‎-‎-‎-80-‎-‎-‎-‎-‎-‎-‎-‎-90-‎-‎-‎-‎-‎-‎-‎-‎-100
0= Impossible‚ 25= Unlikely‚ 50= Possible‚ 75= Likely‚ 100= Certain
b) In the third column rate how awful the consequence would be if it occurred on a scale between 0 and 100 using the second scale below.
0-‎-‎-‎-‎-‎-‎-‎-‎-10-‎-‎-‎-‎-‎-‎-‎-‎-20-‎-‎-‎-‎-‎-‎-‎-‎-30-‎-‎-‎-‎-‎-‎-‎-‎-40-‎-‎-‎-‎-‎-‎-‎-‎-50-‎-‎-‎-‎-‎-‎-‎-‎-60-‎-‎-‎-‎-‎-‎-‎-‎-70-‎-‎-‎-‎-‎-‎-‎-‎-80-‎-‎-‎-‎-‎-‎-‎-‎-90-‎-‎-‎-‎-‎-‎-‎-‎-100
0=Not at all bad‚ 25= Rather bad‚ 50= Bad‚ 75= Really awful‚ 100= The most awful thing possible
 
Consequences
Probability of event
occurring
(0-100: See scale above)
Awfulness if event
occurred
(0-100: See scale above)
I will lose control
 
 
I will choke
 
 
I will become very ill
 
 
I will die
 
 
I will faint
 
 
I will carry on vomiting for ages
 
 
Others will not want to know me
 
 
Others will find me repulsive
 
 
Other (specify): __________________
 
 
Other (specify):__________________
 
 
 
 
31) In your view‚ what is the most awful aspect of either yourself or others vomiting? Please describe.
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
32) This section is for women only (if you are a man‚ please go to question Q33)
a) Have you ever been pregnant?
Yes
No
b) If yes‚ how many times?
Yes
No
c) If yes‚ did you feel sick during any pregnancy?
Yes
No
d) If yes‚ did you vomit during any pregnancy or childbirth?
Yes
No
e) Are you avoiding ha‎ving children because of a fear of vomiting?
Yes
No
f) Have you ever terminated a pregnancy because of a fear of vomiting?
Yes
No
This section is for men. If you are a woman‚ please go to question 34)
33) Have you ever placed pressure on a partner to terminate a pregnancy due to your fear of vomiting?
Yes No
34) Have you ever avoided an operation with an anaesthetic or a treatment that you have been advised to have because of a fear of vomiting?
Yes No
If yes‚ please describe the situation
…………………………………………………………………………………………
…………………………………………………………………………………………
35) Please tell us any foods that you avoid because of your fear of vomiting (e.g. shellfish; eggs).
Then use the scale below to rate the degree of avoidance of each food if you prepare or cook the food as opposed to someone else preparing the food (e.g. in a restaurant). Then describe any details as to why you avoid it.
0-‎-‎-‎-‎-‎-‎-‎-‎-10-‎-‎-‎-‎-‎-‎-‎-‎-20-‎-‎-‎-‎-‎-‎-‎-‎-30-‎-‎-‎-‎-‎-‎-‎-‎-40-‎-‎-‎-‎-‎-‎-‎-‎-50-‎-‎-‎-‎-‎-‎-‎-‎-60-‎-‎-‎-‎-‎-‎-‎-‎-70-‎-‎-‎-‎-‎-‎-‎-‎-80-‎-‎-‎-‎-‎-‎-‎-‎-90-‎-‎-‎-‎-‎-‎-‎-‎-100
0=Never avoid‚ 25= Avoid some of the time‚ 50= Avoid about half of the time ‚ 75=Avoid most of the time‚ 100= Always avoid
Foods avoided
(please specify in
spaces below)
How much
you avoid if
you prepare
or cook the
food
(0-100%)
How much you
avoid if someone
else prepares or
cooks the food
(e.g. in a restaurant)
(0-100%)
Please describe why
you avoid this food
(e.g. fat content or spiciness of the food‚
previous experience of vomiting )
36) Do you restrict the amount of food you eat either in the hope of preventing yourself from vomiting or controlling the amount that you vomit? (Please circle)
Never    Sometimes     Often    Always
37) Do you restrict your food for additional reasons (other than a fear of vomiting)? (Please circle)
Never Sometimes Often Always
Time of day
What do you typically eat?
How much do you
restrict what you eat?
 
 
 
 
If yes to either question‚ please describe what you would eat on a typical day:
38) What is your current weight _________stones ________lbs OR _______kgs
39) What is your current height ______ ft ______ inches OR ________ cms
40) What was your lowest weight at your current height? ______stones_______lbs OR _______kgs
41) Do you excessively smell or check sell by dates of food? (Please circle)
Never Sometimes Often Always
If you do‚ please give details:
…………………………………………………………………………………………
…………………………………………………………………………………………
42) Do you check if others are looking or feeling unwell or sick? (Please circle)
Never Sometimes Often Always
If you do‚ please give details:
…………………………………………………………………………………………
…………………………………………………………………………………………
43) Do you wash your hands frequently or use special measures (e.g. anti-bacterial soap or very hot water) or wash them for an extra long time? (Please circle)
Never Sometimes Often Always
If you do‚ please give details:
…………………………………………………………………………………………
…………………………………………………………………………………………
44) Do you cook your food more than others consider necessary? (Please circle)
Never Sometimes Often Always
If you do‚ please give details:
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
45) Do you engage in any rituals (actions that you have to do repeatedly) or counting in an effort to stop yourself vomiting? (please circle)
Never Sometimes Often Always
If you do‚ please give details
…………………………………………………………………………………………
…………………………………………………………………………………………
 
46) Is there anything else you especially look out for or have an urge to check on to prevent the risk of vomiting in yourself or others? If yes‚ please give details:
…………………………………………………………………………………………
…………………………………………………………………………………………
THIS SECTION IS ONLY FOR THOSE WHO HAVE CHILDREN OR CARE FOR CHILDREN (IF
YOU DO NOT‚ PLEASE GO TO Q48)
47) a) Do you give medication to your children to stop them from vomiting? (Please circle)
Never Sometimes Often Always
If yes‚ what kind of medication?
…………………………………………………………………………………………
…………………………………………………………………………………………
b) Do you restrict their movements? (E.g. going to nursery; visiting friends) (Please circle)
Never Sometimes Often Always
If you do‚ please give details:
…………………………………………………………………………………………
…………………………………………………………………………………………
c) Have you ever abandoned a small child if he or she started to vomit? (Please circle)
Never Sometimes Often Always
If you do‚ please give details:
…………………………………………………………………………………………
…………………………………………………………………………………………
d) Do you get the children in your care to wash their hands frequently or to use special measures (e.g. anti-bacterial soap or very hot water) or to wash them for an extra long time? (Please circle)
Never Sometimes Often Always
If you do‚ please give details:
…………………………………………………………………………………………
…………………………………………………………………………………………
e) Is your relationship with your children compromised in any other way because of your fear of vomiting? (Please circle)
Never Sometimes Often Always
If you are‚ please give details:
…………………………………………………………………………………………
…………………………………………………………………………………………
48) PLEASE COMPLETE THIS SECTION IF YOU LIVE WITH A PARTNER OR A CLOSE FRIEND OR RELATIVE (IF NOT‚ PLEASE GO TO Q49)
a) Do you seek reassurance from the person/people you live with about whether they look ill or could vomit? If yes‚ how often? (Please circle)
Never Sometimes Often Always
If you do‚ please give details:
…………………………………………………………………………………………
…………………………………………………………………………………………
b) Do you attempt to restrict their movements or your joint movements? (Please circle)
Never Sometimes Often Always
If you do‚ please give details:
…………………………………………………………………………………………
…………………………………………………………………………………………
49) Please rate the degree to which you avoid or restrict activities because of your fear of vomiting using the scale below.
0-‎-‎-‎-‎-‎-‎-‎-‎-10-‎-‎-‎-‎-‎-‎-‎-‎-20-‎-‎-‎-‎-‎-‎-‎-‎-30-‎-‎-‎-‎-‎-‎-‎-‎-40-‎-‎-‎-‎-‎-‎-‎-‎-50-‎-‎-‎-‎-‎-‎-‎-‎-60-‎-‎-‎-‎-‎-‎-‎-‎-70-‎-‎-‎-‎-‎-‎-‎-‎-80-‎-‎-‎-‎-‎-‎-‎-‎-90-‎-‎-‎-‎-‎-‎-‎-‎-100
0=Never avoid‚ 25= Avoid some of the time‚ 50= Avoid about half of the time ‚ 75=Avoid most of the time‚ 100= Always avoid
Activity/Place/ Object
avoided because of a
fear of vomiting
How much
you avoid
(0-100%)
Please describe and give details about what you
avoid or specific measures you use if you can’t
avoid it
Public Toilets
 
 
Eating at Restaurants
 
 
Eating from salad bars or buffets
 
 
Eating food that you have
not prepared yourself
 
 
Speaking in Public
 
 
Sitting Exams
 
 
Holidays Abroad
 
 
Visiting the Dentist
 
 
Attending an Interview
 
 
Visiting your GP
 
 
Illegal Drugs
 
 
Alcohol
 
 
Crowded Places
 
 
Places where I can’t cook for myself
 
 
Drunks
 
 
Pubs
 
 
 
 
Avoidance (continued)
0-‎-‎-‎-‎-‎-‎-‎-‎-10-‎-‎-‎-‎-‎-‎-‎-‎-20-‎-‎-‎-‎-‎-‎-‎-‎-30-‎-‎-‎-‎-‎-‎-‎-‎-40-‎-‎-‎-‎-‎-‎-‎-‎-50-‎-‎-‎-‎-‎-‎-‎-‎-60-‎-‎-‎-‎-‎-‎-‎-‎-70-‎-‎-‎-‎-‎-‎-‎-‎-80-‎-‎-‎-‎-‎-‎-‎-‎-90-‎-‎-‎-‎-‎-‎-‎-‎-100
0=Never avoid‚ 25= Avoid some of the time‚ 50= Avoid about half of the time ‚ 75=Avoid most of the time‚ 100= Always avoid
Activity/Place/ Object
avoided because of a fear of
vomiting
How much
you avoid
(0-100%)
Please describe and give details about what you
avoid or specific measures you use if you do can’t
avoid it
Public Transportation (buses‚ trains‚ etc.)
 
 
Sea travel by boat
 
 
Travel by aero plane
 
 
Driving a car
 
 
Being a passenger in a car
 
 
Visiting others who are ill in
hospital
 
 
Receiving treatment in hospital
 
 
Adults who are ill or might vomit
 
 
Children or babies who areill or might vomit
 
 
Certain Films or television programs
 
 
Fairground Rides
 
 
Places that smell of vomit
 
 
Certain words relating to vomiting (please give details)
 
If yes‚ what words do you use?
Foreign holidays (even if the travel was possible)
 
 
Other
 
 
 
 
 
 
 
50) If you have a partner‚ please answer 50a. If you do not have a partner‚ please answer 50b.
a) To what extent does your fear of vomiting currently have an effect on your relationship with an existing partner? (e.g. affectionate feelings‚ number of arguments‚ enjoying activities together)
0-‎-‎-‎-‎-‎-‎-‎-‎-1-‎-‎-‎-‎-‎-‎-‎-‎-2-‎-‎-‎-‎-‎-‎-‎-‎-3-‎-‎-‎-‎-‎-‎-‎-‎-4-‎-‎-‎-‎-‎-‎-‎-‎-5-‎-‎-‎-‎-‎-‎-‎-‎-6-‎-‎-‎-‎-‎-‎-‎-‎-7-‎-‎-‎-‎-‎-‎-‎-‎-8
0= Not at all‚ 2= Slightly‚ 4= Moderately‚ 6= Markedly‚ 8= Extremely
If so‚ how does it affect your relationship?
…………………………………………………………………………………………
…………………………………………………………………………………………
b) If you do not have a partner‚ to what extent does your fear of vomiting currently have an effect on dating or developing a relationship?
0-‎-‎-‎-‎-‎-‎-‎-‎-1-‎-‎-‎-‎-‎-‎-‎-‎-2-‎-‎-‎-‎-‎-‎-‎-‎-3-‎-‎-‎-‎-‎-‎-‎-‎-4-‎-‎-‎-‎-‎-‎-‎-‎-5-‎-‎-‎-‎-‎-‎-‎-‎-6-‎-‎-‎-‎-‎-‎-‎-‎-7-‎-‎-‎-‎-‎-‎-‎-‎-8
0= Not at all‚ 2= Slightly‚ 4= Moderately‚ 6= Markedly‚ 8= Extremely
If so‚ how does it affect your ability to date or have a relationship?
…………………………………………………………………………………………
…………………………………………………………………………………………
51) To what extent does your fear of vomiting currently have an effect on a sexual relationship? (e.g. enjoyment of sex‚ frequency of sexual activity)
0-‎-‎-‎-‎-‎-‎-‎-‎-1-‎-‎-‎-‎-‎-‎-‎-‎-2-‎-‎-‎-‎-‎-‎-‎-‎-3-‎-‎-‎-‎-‎-‎-‎-‎-4-‎-‎-‎-‎-‎-‎-‎-‎-5-‎-‎-‎-‎-‎-‎-‎-‎-6-‎-‎-‎-‎-‎-‎-‎-‎-7-‎-‎-‎-‎-‎-‎-‎-‎-8
0= Not at all‚ 2= Slightly‚ 4= Moderately‚ 6= Markedly‚ 8= Extremely I avoid sex
If so‚ how?
…………………………………………………………………………………………
…………………………………………………………………………………………
….Tick‚ if no sexual relationship for reasons other than avoiding sex because of your problem
52) To what extent does your fear of vomiting currently interfere with your ability to work or study‚ or your role as a homemaker? (Please rate this even if you are not working or studying: we are interested in your ability to work or study.)
0-‎-‎-‎-‎-‎-‎-‎-‎-1-‎-‎-‎-‎-‎-‎-‎-‎-2-‎-‎-‎-‎-‎-‎-‎-‎-3-‎-‎-‎-‎-‎-‎-‎-‎-4-‎-‎-‎-‎-‎-‎-‎-‎-5-‎-‎-‎-‎-‎-‎-‎-‎-6-‎-‎-‎-‎-‎-‎-‎-‎-7-‎-‎-‎-‎-‎-‎-‎-‎-8
0= Not at all‚ 2= Slightly‚ 4= Moderately‚ 6= Markedly‚ 8= Very severely I can’t work
If so‚ how does your fear affect it most?
…………………………………………………………………………………………
…………………………………………………………………………………………
How many working days have you lost in the past year because of your fear?……
53) To what extent does your fear of vomiting currently interfere with your social life? (with other people‚ e.g. parties‚ pubs‚ clubs‚ outings‚ visits‚ home entertainment)
0-‎-‎-‎-‎-‎-‎-‎-‎-1-‎-‎-‎-‎-‎-‎-‎-‎-2-‎-‎-‎-‎-‎-‎-‎-‎-3-‎-‎-‎-‎-‎-‎-‎-‎-4-‎-‎-‎-‎-‎-‎-‎-‎-5-‎-‎-‎-‎-‎-‎-‎-‎-6-‎-‎-‎-‎-‎-‎-‎-‎-7-‎-‎-‎-‎-‎-‎-‎-‎-8
0= Not at all‚ 2= Slightly‚ 4= Moderately‚ 6= Markedly‚ 8= Very severely
If so‚ how does it affect it most?
…………………………………………………………………………………………
…………………………………………………………………………………………
54) To what extent does your fear of vomiting currently interfere with your private leisure activities? (done alone) (e.g. reading; gardening; collecting; walking alone etc)
0-‎-‎-‎-‎-‎-‎-‎-‎-1-‎-‎-‎-‎-‎-‎-‎-‎-2-‎-‎-‎-‎-‎-‎-‎-‎-3-‎-‎-‎-‎-‎-‎-‎-‎-4-‎-‎-‎-‎-‎-‎-‎-‎-5-‎-‎-‎-‎-‎-‎-‎-‎-6-‎-‎-‎-‎-‎-‎-‎-‎-7-‎-‎-‎-‎-‎-‎-‎-‎-8
0= Not at all‚ 2= Slightly‚ 4= Moderately‚ 6= Markedly‚ 8= Very severely
If so‚ how does it affect it most?
…………………………………………………………………………………………
…………………………………………………………………………………………
55) To what extent does your fear of vomiting currently interfere with your home management? (e.g. cleaning‚ tidying‚ shopping‚ cooking‚ looking after your home or children‚ paying bills etc)
0-‎-‎-‎-‎-‎-‎-‎-‎-1-‎-‎-‎-‎-‎-‎-‎-‎-2-‎-‎-‎-‎-‎-‎-‎-‎-3-‎-‎-‎-‎-‎-‎-‎-‎-4-‎-‎-‎-‎-‎-‎-‎-‎-5-‎-‎-‎-‎-‎-‎-‎-‎-6-‎-‎-‎-‎-‎-‎-‎-‎-7-‎-‎-‎-‎-‎-‎-‎-‎-8
0= Not at all‚ 2= Slightly‚ 4= Moderately‚ 6= Markedly‚ 8= Very severely
If so‚ how does it affect it most?
…………………………………………………………………………………………
…………………………………………………………………………………………
56) On an average day over the past week‚ how much time do you spend worrying about yourself or others vomiting? (This includes thinking about how to prevent it)
________minutes OR _______hours a day
57) To what extent does your worry about vomiting preoccupied you over the past week? That is‚you think about it a lot and it is hard to stop thinking about it?
0-‎-‎-‎-‎-‎-‎-‎-‎-1-‎-‎-‎-‎-‎-‎-‎-‎-2-‎-‎-‎-‎-‎-‎-‎-‎-3-‎-‎-‎-‎-‎-‎-‎-‎-4-‎-‎-‎-‎-‎-‎-‎-‎-5-‎-‎-‎-‎-‎-‎-‎-‎-6-‎-‎-‎-‎-‎-‎-‎-‎-7-‎-‎-‎-‎-‎-‎-‎-‎-8
0= Not at all preoccupied‚ 2= slightly preoccupied‚ 4= moderately preoccupied‚ 6= Markedly preoccupied‚ 8= Very Extremely preoccupied
58) How distressing has your fear of vomiting been in the past week?
0-‎-‎-‎-‎-‎-‎-‎-‎-1-‎-‎-‎-‎-‎-‎-‎-‎-2-‎-‎-‎-‎-‎-‎-‎-‎-3-‎-‎-‎-‎-‎-‎-‎-‎-4-‎-‎-‎-‎-‎-‎-‎-‎-5-‎-‎-‎-‎-‎-‎-‎-‎-6-‎-‎-‎-‎-‎-‎-‎-‎-7-‎-‎-‎-‎-‎-‎-‎-‎-8
0= Not at all distressing‚ 2= Slightly‚ 4= Moderately‚ 6= Markedly‚ 8= Extremely distressing
59) How well do you think you would cope with an episode of vomiting in the future?
0-‎-‎-‎-‎-‎-‎-‎-‎-1-‎-‎-‎-‎-‎-‎-‎-‎-2-‎-‎-‎-‎-‎-‎-‎-‎-3-‎-‎-‎-‎-‎-‎-‎-‎-4-‎-‎-‎-‎-‎-‎-‎-‎-5-‎-‎-‎-‎-‎-‎-‎-‎-6-‎-‎-‎-‎-‎-‎-‎-‎-7-‎-‎-‎-‎-‎-‎-‎-‎-8
0= Not at all‚ 2= with difficulty‚ 4= reasonably‚ 6= fairly well‚ 8= very well
60) To what extent do you believe you can influence or prevent yourself vomiting from any cause in the future?
0-‎-‎-‎-‎-‎-‎-‎-‎-1-‎-‎-‎-‎-‎-‎-‎-‎-2-‎-‎-‎-‎-‎-‎-‎-‎-3-‎-‎-‎-‎-‎-‎-‎-‎-4-‎-‎-‎-‎-‎-‎-‎-‎-5-‎-‎-‎-‎-‎-‎-‎-‎-6-‎-‎-‎-‎-‎-‎-‎-‎-7-‎-‎-‎-‎-‎-‎-‎-‎-8
0= Not at all‚ 2= Slightly‚ 4= Moderately‚ 6= Markedly‚ 8= Totally All
61) This next section is for treatments that you have had for your fear of vomiting.
Please rate the effectiveness of each therapy that you received using the scale below.
0-‎-‎-‎-‎-‎-‎-‎-‎-1-‎-‎-‎-‎-‎-‎-‎-‎-2-‎-‎-‎-‎-‎-‎-‎-‎-3-‎-‎-‎-‎-‎-‎-‎-‎-4-‎-‎-‎-‎-‎-‎-‎-‎-5-‎-‎-‎-‎-‎-‎-‎-‎-6-‎-‎-‎-‎-‎-‎-‎-‎-7-‎-‎-‎-‎-‎-‎-‎-‎-8-‎-‎-‎-‎-‎-‎-‎-‎-9-‎-‎-‎-‎-‎-‎-‎-‎-10
0= Not effective at all‚ 2= Mildly Effective‚ 4= Moderately Effective‚ 6= Very Effective‚ 8= Extremely Effective‚10= (no longer at all fear vomit)
a) Have you had behaviour therapy (exposure) or cognitive behaviour therapy?
Yes No
If yes‚ please give details about what it consisted of‚ when and by whom it was delivered and how effective it was using the scale above?
…………………………………………………………………………………………
…………………………………………………………………………………………
b) Have you ever been prescribed and taken any psychiatric medication for your fear of vomiting?
Yes No
If yes‚ please give name of medication and dosage‚ with the dates when you took it‚ and say how effective it was.
…………………………………………………………………………………………
…………………………………………………………………………………………
c) Have you had any other types of therapy (e.g. hypnotherapy) for your fear of vomiting?
Yes No
If yes‚ please describe what it consisted of and give details and how effective it was?
…………………………………………………………………………………………
…………………………………………………………………………………………
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