Self-diagnosing questionnaire

Name (can be fictional) *

Email *

1. Describe the behavior you want to take a closer look at *

2. Would you qualify this behavior at this point as *

Clarify your choice *

3. You have tried to control or stop the behavior *

4. You don't want anyone to know *

5. You have exercised the behavior at inappropriate times, places or with inappropriate people *

6. You are keeping track of the behavior *

7. You feel guilty or depressed *

8. Exercising this behavior makes your life bearable *

9. You feel desperate about this behavior *

10. Your behavior intensifies *

11. The behavior is affecting your credibility/reputation *

12. Your life is becoming unmanageable/getting out of control *

13. You could do more with your life if you were not driven by this behavior *

14. You have been in trouble because of the behavior *

15. You are investing too much time and energy in the behavior *

16. The behavior is affecting your relationships *

17. It bothers you when someone expresses concern *

18. You could be blackmailed with your behavior *

19. Do you sometimes feel you are going crazy *

20. Rate the quality of your life

Selected Value: 0

Personal reflections *

Gino Peremans