Survey[1]
On a scale of 1 to 10, where 1 is low/easy/not at all and 10 is high/difficult/frequently:
How much do you worry about what other people think of you?
1 2 3 4 5 6 7 8 9 10
_________________________________________________________
How important is it for you to please others?
1 2 3 4 5 6 7 8 9 10
_________________________________________________________
How would you rate your level of worry?
1 2 3 4 5 6 7 8 9 10
_________________________________________________________
How would you rate your current level of exhaustion?
1 2 3 4 5 6 7 8 9 10
__________________________________________________________
How much would you say you worry at night when you are falling asleep?
1 2 3 4 5 6 7 8 9 10
___________________________________________________________
How hard is it to fall asleep at night?
1 2 3 4 5 6 7 8 9 10
___________________________________________________________
Are you a worrier?
Yes No
Is it hard to fall asleep?
Yes No
Do you feel that you are easily influenced by other people’s opinions?
Yes No
Do you worry a lot at night when you go to bed?
Yes No
Have you noticed any other changes?
Yes No
If yes, describe what changes you have noticed.
[1] From The Intuitive Dance by Atherton Drenth. © 2016 by Atherton Drenth. Used by permission from Llewellyn Worldwide, Ltd., www.Llewellyn.com
