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Personal Details?
 
Male
 
female
 
 
 
Age?
 
-15
 
16-25
 
26-35
 
36-45
 
46-55
 
56-65
 
66-
 
 
 
Do you have a phobia?
 
Yes
 
No
 
Not sure
 
 
 
do you know someone who has a phobia?
 
yes
 
no
 
 
 
what phobia do you suffer from?
 
fear of spiders
 
fear of flying
 
fear of the dentist
 
social phobia
 
fear of confined space
 
fear of public speaking
 
Other
 
 
 
 
Do you think your phobia effects your life?
 
yes
 
no
 
if yes how
 
 
 
 
Have you been medically/psychologically treated for your phobia?
 
yes
 
no
 
 
 
Can you attribute the onset of your phobia to a specific event?
 
no
 
yes
 
 
 
Had that event not occurred, do you think you would still have a phobia?
 
yes
 
no
 
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