This form will help us to maintain our quality control and evaluate the
effectiveness of Sudotherapay. All fields with an
asterisk (*) must be completed.
*Are you completing this questionnaire pre-treatment (before looking at Sudo each day for 7 days, 10 minutes a day) or post-treatment (after looking at Sudo each day for 7 days, 10 minutes a day)?
*Which condition are / will you be in (A or B)
Please provide the following contact information (optional):
Please identify and describe yourself (for pre- to post-treatment comparison) :
*Please choose one of the following options which best describes your trauma:
Witnessed any of the above
*What is your anxiety rating when imagining your trauma - 0 (no anxiety) up to 100 (highest possible)?
Below is a list of
difficulties people sometimes have after stressful life events. Please read each
item, and then indicate how distressing each difficulty has been for you.
DURING THE PAST SEVEN DAYS with respect to your trauma how much
were you distressed or bothered by these difficulties?
*Any reminder brought back feelings about it
*I had trouble staying asleep
*Other things kept making me think about it
*I felt irritable and angry
*I avoided letting myself get upset when I thought about it or was reminded of it
*I thought about it when I didn't mean to
*I felt as if it hadn't happened or wasn't real
*I stayed away from reminders about it
*Pictures about it popped into my mind
*I was jumpy and easily startled
*I tried not to think about it
*I was aware that I still had a lot of feelings about it, but I didn't deal with them
*My feelings about it were kind of numb
*I found myself acting or feeling as though I was back at that time
*I had trouble falling asleep
*I had waves of strong feelings about it
*I tried to remove it from my memory
*I had trouble concentrating
*Reminders of it caused me to have physical reactions, such as sweating, trouble breathing, nausea, or a pounding heart
*I had dreams about it
*I felt watchful or on-guard
*I tried not to talk about it
Please add any comments you may have below