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Chestionar

Drowning Phobia Questionnaire


Age:
Gender : masculin/feminin
1. Where are you from :
Rural
Urban
2. Do you think learning to swim is vital for survival?
Not at all
Somewhat
Very much
3. At what age did you learned to swim?
5-10
10-15
15-20
20-25
25-30
4. How good are you at swim?
Beginner
Medium
Advanced
Expert
5. What techniques of swimming do you know?
Crawl on chest
Crawl on back
Breast stroke
Butterfly
6. Do you suffer from fear of water (aquaphobia) ?
Yes
No
7. On a scale of 1 to 10, how serious is your drowning phobia ?
Scale: 1 2 3 4 5 6 7 8 9 10
8. Did you ever assist at a drowning incident?
Yes
No
9. How bad are your symptoms of drawning phobia ?
The symptoms are reallybad and i have used drugs.
The symptoms are really bad but ive avoided using meds.
The symptoms are unconfortable and ive used drogs
The symptoms are unconfortable and ive not used meds
I dont really experienced significant symptoms
10. Do you dramatize situations involving water or drawning in your mind ... Do you see
pictures or movies, or hear self-talk or other dialog in your mind?

Yes, all the time and the feelings are powerful.


Sometimes and the feelings are bad when i do.
Sometimes, but the feelings arent that bad.
A little
Never.
11. Do you fear that if you are drowning, nobody can reach to save you?
Not at all
Somewhat
Very much
12. To what degree has this issue your relationship with your family, friends & coworkers. Do you find it difficult to explain what you are going through, or even keep it
a secret?
Extreme impact on relationship
Significant impact
It has made things difficult at times
A little, not too bad
None
13. Overall, When you think about the impacts this is having in your life, how bad is the
problem ?
Its ruining my life
It has considerable impact and has to be dealt with
Life would be alot better without drowning phobia
Its not great but im ok
No impact really
14. Do you worry about dying?
Not at all
Somewhat
Very much
15. Does it bother you that you may die before you have done everything you wanted to
do?
Not at all
Somewhat
Very much
16. Do you worry that dying may be very painful?
Not at all
Somewhat
Very much
17. Does it upset you to think others may see you suffering before you die?
Not at all
Somewhat
Very much
18. Do you worry that the persons closest to you wont be with you when you are dying?
Not at all
Somewhat
Very much

19. Does the thought of leaving loved ones behind when you die disturb you?
Not at all
Somewhat
Very much
20. Do you worry that those you care aboyt may not remember you after your death?
Not at all
Somewhat
Very much
21. Are you worried about not knowing what to expect after death?
Not at all
Somewhat
Very much
22. Does the thought worry you that with death you may be gone forever?
Not at all
Somewhat
Very much

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