Q1: What is it about V*ing that causes you the greatest distress?
a) Being out of control of my body
b) Feels foreign/don't know how to do it
c) Afraid it could aspirate to my lungs
d) The smell/sight/sensation of it
e) Belief that I won't be prepared for it
f) Embarrassment if in front of others
g) None of the above
Q2: As an emetophobe, do you additionally suffer from any of the following?
a) Irritable Bowel Syndrome
b) Gastritis
c) Generalized Anxiety Disorder
d) Panic Disorder
e) Depression
f) Obsessive Compulsive Disorder
g) None of the above
h) Some of the above (please specify)
Q3: If someone near you were V*ing due to non-contagious reasons (ie: morning sickness, drinking too much alcohol, etc), you would:
a) Still be scared/panic/afraid since it's V
b) Not be afraid/panic since it's not contagious
c) Still be scared, but to a lesser extent since it's non-contagious
d) None of the above (please explain)
Q4: The last time you V*ed was:
a) Never V*ed in your life
b) In the last year
c) In the last 2-4 years
d) In the last 6-10 years
e) In the last 10-15 years
f) In the last 15-20 years
g) It's been over 20 years
Q5: Please state your age and the number of times you've contracted an SV in you life:
I'm sixteen and I have had a SV once, which was after Thanksgiving in 2011. My grandma got it, then passed it on to the family. It wasn't FP because my dad did not come to Thanksgiving at my aunt's house or eat any of the food. He was sick with the SV as well.