Misophonia Part C Misophonia Part C"*" indicates required fieldsName*Birthday* MM slash DD slash YYYY Please only select ONE statement in each category that best describes what you experience for emotional response and physical sensation. “Trigger sound” refers to a sound that causes issues for you.Emotional Response*Select your choice(0) I hear a known trigger sound but feel no discomfort(1) I am aware of the presence of a known trigger person but feel no, or minimal, anticipatory anxiety.(2) Known trigger sounds elicit minimal psychic discomfort, irritation or annoyance. No symptoms of panic or fight or flight response.(3) I feel increasing levels of psychic discomfort but do not engage in any physical response. I may be hyper vigilant to audio-visual stimuli.(4) I engage in a minimal physical response – non-confrontational coping behaviors, such as asking the trigger person to stop making the noise, discreetly covering one ear, or by calmly moving away from the noise. No panic or fight or flight symptoms exhibited.(5) I adopt more confrontational coping mechanisms, such as overtly covering my ears, mimicking the trigger person, make repeated sounds, or display overt irritation.(6) I experience substantial psychic discomfort. Symptoms of panic and a fight or flight response begin to engage.(7) I experience substantial psychic discomfort. Increasing use (louder, more frequent) use of confrontational coping mechanisms. I may re-imagine the trigger sound and visual cues over and over again, sometimes for weeks, months or even years after the event.(8) I experience substantial psychic discomfort and some violence thoughts.(9) Panic/rage reaction in full swing. Conscious decision not to use violence on trigger person. Actual flight from vicinity of noise and/or use of physical violence on an inanimate object. Panic, anger or severe irritation may be manifest in my demeanor.10) Actual use of physical violence on a person or animal (i.e., a household pet). Violence may be inflicted on self (self-harming).Physical Sensation*Select your choice(0) I feel no physical sensation.(1) I feel minimal physical sensation and can ignore it.(2) I feel some physical sensation but can often/always ignore it.(3) I feel some physical sensation but have difficulty or cannot ignore it.(4) I feel elevated physical sensation and usually cannot ignore it.(5)I feel elevated physical sensation, definitely cannot ignore it(6) I feel elevated physical sensation, cannot ignore it and each incidence has an impact on my life(7) I feel physical sensation as described above and cannot cope with it(8) I feel physical sensation which can be best described as emotional pain(9) I feel physical sensation which can be best described as physical pain(10) I feel physical sensation which is overpowering and is causing physical painAny Additional Comments: