PREVIEW MODE — This is a preview of the patient questionnaire
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1.People have not been there to meet my emotional needs.

A.Completely untrue of me
B.Mostly untrue of me
C.Slightly more true than untrue
D.Moderately true of me
E.Mostly true of me
F.Describes me perfectly

2.I haven't gotten enough love and attention.

A.Completely untrue of me
B.Mostly untrue of me
C.Slightly more true than untrue
D.Moderately true of me
E.Mostly true of me
F.Describes me perfectly

3.For the most part, I haven't had someone to depend on for advice and emotional support.

A.Completely untrue of me
B.Mostly untrue of me
C.Slightly more true than untrue
D.Moderately true of me
E.Mostly true of me
F.Describes me perfectly

4.Most of the time, I haven't had someone to nurture me, share him/herself with me, or care deeply about everything that happens to me.

A.Completely untrue of me
B.Mostly untrue of me
C.Slightly more true than untrue
D.Moderately true of me
E.Mostly true of me
F.Describes me perfectly

5.For much of my life, I haven't had someone who wanted to get close to me and spend a lot of time with me.

A.Completely untrue of me
B.Mostly untrue of me
C.Slightly more true than untrue
D.Moderately true of me
E.Mostly true of me
F.Describes me perfectly

6.In general, people have not been there to give me warmth, holding, and affection.

A.Completely untrue of me
B.Mostly untrue of me
C.Slightly more true than untrue
D.Moderately true of me
E.Mostly true of me
F.Describes me perfectly

7.For much of my life, I haven't felt that I am special to someone.

A.Completely untrue of me
B.Mostly untrue of me
C.Slightly more true than untrue
D.Moderately true of me
E.Mostly true of me
F.Describes me perfectly

8.For the most part, I have not had someone who really listens to me, understands me, or is tuned into my true needs and feelings.

A.Completely untrue of me
B.Mostly untrue of me
C.Slightly more true than untrue
D.Moderately true of me
E.Mostly true of me
F.Describes me perfectly

9.I have rarely had a strong person to give me sound advice or direction when I'm not sure what to do.

A.Completely untrue of me
B.Mostly untrue of me
C.Slightly more true than untrue
D.Moderately true of me
E.Mostly true of me
F.Describes me perfectly

10.I worry that the people I love will die soon, even though there is little medical reason to support my concern.

A.Completely untrue of me
B.Mostly untrue of me
C.Slightly more true than untrue
D.Moderately true of me
E.Mostly true of me
F.Describes me perfectly