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Follow-up
Intro
Date
Name
Date of birth
Adress
Phone Nr
e-mail
Profession
Married/single
Height/Weight
Smoking
Choose
Yes
No
Alcohol/week
Drugs
ETS/ESB and time
Worst symptoms
1.
2.
Treatment after surgery
None
Psycho- or Hypnotherapy
Iontophoresis
Medication
Estimate the degree of your symptoms by scoring from 1 (nearly normal) to 4 (unbearable)
Social anxiety BEFORE
1
2
3
4
Stage fright
Social situations
Difficult eye contact
Fear of being scrutinized
Embarrassement
Social anxiety AFTER
1
2
3
4
Stage fright
Social situations
Difficult eye contact
Fear of being scrutinized
Embarrassement
Physical problems BEFORE
1
2
3
4
Handsweat
Facial sweating
Lower body sweating
Blushing
Trembling
Lack of energy
Physical problems AFTER
1
2
3
4
Handsweat
Facial sweating
Lower body sweating
Blushing
Trembling
Lack of energy
Describe your situation now
Would you still take the block in a similar situation
Choose
Yes
No
Proceed