Questionnaire (Mobility Inventory)

Hello! Please click the button below to complete a short questionnaire. Doing this regularly is one way we can track how therapy is going. Your responses will be emailed directly to Dr Forzisi.

Please indicate the degree to which you avoid the following places or situations because of discomfort or anxiety. Rate your amount of avoidance when you are with a trusted companion and when you are alone. Do this by using the following scale.
1. Never avoid 2. Rarely avoid 3. Avoid about half the time 4. Avoid most of the time 5. Always avoid
(You may use numbers half-way between those listed when you think it is appropriate. For example, 3.5 or 4.5). Write your score in the blanks for each situation or place under both conditions:when accompanied,and, when alone. Leave blank those situations that do not apply to you.
OPEN SPACES
RIDING IN:
SITUATIONS:
Please specify and rate as above.