Evaluation

To evaluate the need and benefit of ESB-surgery

Contact info

Name

Family name

Date of birth

Address

Postal code and Town

Telephone

e-mail

Profession

Next of kin

Height/weight

Basics

	Yes	No
Smoking
Drugs

	Daily	Weekly	Seldom	Never
Alcohol

My most disturbing problems

1.

2.

Fear and avoidance

	Not usually	Seldom	Very much	Tremendously
Stage fright
Fear of embarrassment
Fear of social situations
Avoidance of gaze contact
Fear of being scrutinized

	No	A little	Bad	Unbearable
Depression

Bodily signs

	Not usually	A little	Bad	Unbearable
Handsweat
Facial sweating
Footsweat
Underam sweating
Heart racing
Blushing
Trembling of the hands or the head

Mark the previous treatment

Psycho- or hypnotherapy

Medication

Beta-blockers

SSRI

Tranquilizers

Tell us some more

Sending the information