SUGGESTIBILITY
Full Name
First Name
Last Name
What is your age?
What is your gender?
Please Select
Male
Female
N/A
Contact Number
Email Address
example@example.com
Have you ever walked in your sleep during your adult life?
Yes
No
As A teenager, did you feel comfortable expressing your feelings to one or both of your parents?
Yes
No
Do you have a tendency to look directly into a persons eyes and or move closely to them when discussing an interesting subject?
Yes
No
Do you feel that most people, when you first meet them, are uncritical of your appearance?
Yes
No
In a group situation with people you have just met, would you feel comfortable drawing attention to yourself by initiating a conversation?
Yes
No
Do you feel comfortable holding hands or hugging someone you are in a relationship with in front of other people?
Yes
No
When someone talks about feeling warm physically, do you begin to feel warm also?
Yes
No
Do you tend to occasionally tune out when someone is talking to you because you are anxious to come up with your side, and, at times, not hear what the other person said?
Yes
No
Do you feel that you learn and comprehend better by seeing and/or reading than by hearing?
Yes
No
In a new class or lecture situation, do you usually feel comfortable asking questions in front of a group?
Yes
No
When expressing your ideas, do you find it important to relate all of the details leading up to the subject so that the other person can understand it completely?
Yes
No
Do you enjoy relating to children?
Yes
No
Do you find it easy to be at ease and comfortable with your body movements? Even when faced with unfamiliar people or circumstances?
Yes
No
Do you prefer reading fiction rather than nonfiction?
Yes
No
If you were to imagine sucking on a sour, bitter, juicy, yellow lemon, would your mouth begin to water?
Yes
No
If you feel that you deserve to be complimented for something well done, do you feel comfortable if the compliment is given in front of other people?
Yes
No
Do you feel that you are a good conversationalist?
Yes
No
Do you feel comfortable when complementary attention is drawn to your physical body or appearance?
Yes
No
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SUGGESTIBILITY
Have you ever awakened in the middle of the night and felt you could not move your body and /or talk?
Yes
No
As a child, did you feel that you were more affected by your parents tone of voice, then by what they actually said?
Yes
No
If someone you are associated with talks about a fear that you have experienced before, do you have a tendency to have an apprehensive or fearful feeling also?
Yes
No
After having an argument with someone, do you have a tendency to dwell on what you could or should have said?
Yes
No
Do you tend to occasionally tune out when someone is talking to you and, therefore, do not hear what was said because your mind drifts to something completely unrelated?
Yes
No
Do you sometimes desire to be complimented for a job well done, but feel embarrassed or uncomfortable when complimented?
Yes
No
Do you often have a fear or dread of not being able to carry on a conversation with someone you have just met?
Yes
No
Do you feel self-conscious when attention is drawn to your physical body or appearance?
Yes
No
If you had a choice, would you rather avoid being around children most of the time?
Yes
No
Do you feel that you are not relaxed or loose in your body movements especially when face with unfamiliar people or circumstances?
Yes
No
Do you prefer reading nonfiction rather than fiction?
Yes
No
If someone describes a very bitter taste, do you have difficulty experiencing the physical feeling of it?
Yes
No
Do you generally feel that you see yourself less favorably than others see you?
Yes
No
Do you feel awkward or self-conscious initiating touch holding hands, kissing, etc. with someone you were in a relationship with, in front of other people?
Yes
No
In a new class lecture situation, do you usually feel uncomfortable asking questions in front of a group, even though you may desire further explanation?
Yes
No
Do you feel uneasy if someone you’ve just met, looks directly into your eyes when talking to you, especially if the conversation is about you?
Yes
No
In a group situation with people you just met, would you feel uncomfortable drawing attention to yourself by initiating conversation?
Yes
No
iI you were in a relationship, or very close to someone, do you find it difficult or embarrassing to verbalize your love for them?
Yes
No
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