Name: _________________________ Date: _________

MISOPHONIA ASSESSMENT QUESTIONNAIRE (MAQ)

If a parent or caregiver, please answer for the child as best you are able, or substitute the words, “I feel
that my child’s sound issues” for the words “my sound issues”.

RATING SCALE:
0 1 2 3
0 = not at all, 1 = a little of the time, 2 = a good deal of the time, 3 = almost all the time
1. My sound issues currently make me unhappy

2. My sound issues currently create problems for me.

3. My sound issues have recently made me feel angry.

4. I feel that no one understands my problems with certain sounds.

5. My sound issues do not seem to have a known cause.

6. My sound issues currently make me feel helpless.

7. My sound issues currently interfere with my social life.

8. My sound issues currently make me feel isolated.

9. My sound issues have recently created problems for me in groups.

10. My sound issues negatively affect my work/school life (currently or

recently).
11. My sound issues currently make me feel frustrated.

12. My sound issues currently impact my entire life negatively.

13. My sound issues have recently made me feel guilty.
14. My sound issues are classified as ‘crazy’.

15. I feel that no one can help me with my sound issues.

16. My sound issues currently make me feel hopeless.

17. I feel that my sound issues will only get worse with time.
18. My sound issues currently impact my family relationships.

19. My sound issues have recently affected my ability to be with other

people.
20. My sound issues have not been recognized as legitimate.

21. I am worried that my whole life will be affected by sound issues.

By Marsha Johnson, revised by Tom Dozier

Revised 07/20/13
Name: ______________________________________________ Date: _____________

Amsterdam Misophonia Scale (A-MISO-S)*

Rate the characteristics of each item during the prior week up until and including the time you fill out this
survey. Scores should reflex the average (mean) occurrence of each item for the entire week.

1. How much of your time is occupied by misophonic triggers? (How frequently do the (thoughts
about the) misophonic triggers occur?)

None 0
Mild, less than 1 hr/day,or occasionally (thoughts about ) triggers (no more than 5 times
1
a day)
Moderate, 1 to 3 hrs/day, or frequent (thoughts about) triggers (no more than 8 times a
2
day, most of the hours are unaffected).
Severe, greater than 3 hrs and up to 8 hrs/day or very frequent (thoughts about) triggers. 3

Extreme, greater than 8 hrs/day or near constant (thoughts about) triggers. 4

2. How much do these misophonic triggers interfere with your social, work or role functioning? (Is
there anything that you don’t do because of them? If currently not working determine how much
performance would be affected if you were employed.)

None 0
Mild, slight interference withi social or occupational/school activities, but overall
1
performance not impaired.
Moderate, definite interference with social or occupational performance, but still
2
manageable.
Severe, causes substantial impairment in social or occupational performance. 3

Extreme, incapacitating. 4

3. How much distress do the misophonic triggers cause you? (In most cases, distress is equated with
irritation, anger, or disgust. Only rate the emotion that seems triggered by misophonic triggers, not
generalized irritation or irritation associated with other conditions.)

None 0

Mild, occasional irritation/distress. 1

Moderate, disturbing irritation/anger/disgust, but still manageable. 2

Severe, very disturbing irritation/anger/disgust. 3

Extreme, near constant and disturbing anger/disgust. 4

Amsterstam Misophonia Scale (A-MISO-S) from Schröder, A., Vulink, N., & Denys, S. (2013). Misophonia:
*Diagnostic criteria for a new psychiatric disorder. PLoS ONE, 8(1), e54706. doi:10.1371/journal.pone.0054706

Note: This form has been modified by replacing “sounds” with “triggers” to include visual and sound triggers.
4. How much effort do you make to resist the (thoughts about the) misophonic triggers? (How often
do you try to disregard or turn your attention away from these triggers? Only rate effort made to resist,
not success or failure in actually controlling the thought or trigger.)
Makes an effort to always resist, or symptoms so minimal, doesn’t need to actively
0
resist.
Tries to resist most of the time. 1

Makes some effort to resist. 2

Yields to all (thoughts about) misophonic triggers without attempting to
3
control them, but does so with some reluctance.
Completely and willing yields to all obsessions. 4

5. How much control do you you have over your thoughts about the misophonic triggers? How
successful are you in stopping or diverting your thinking about the misophonic triggers? Can you dismiss
them?

Complete control. 0

Much control, usually able to stop or divert thoughts about misophonic triggers. 1

Moderate control, sometimes able to stop or divert thoughts about misophonic triggers. 2
Little control, rarely successful in stopping or dismissing thoughts about misophonic
3
triggers, can only divert attention with difficulty.
No control, experience thoughts as completely involuntary, rarely able to alter thinking
4
about misophonic triggers.

6. Have you been avoiding doing anything, going any place, or being with anyone because of your
misophonia? (How much do you avoid, for example, by using other loud sounds, such as music?)

No deliberate avoidance. 0

Mild, minimal avoidance, Less than an hr/day or occasional avoidance. 1

Moderate, some avoidance. 1 to 3 hr/day or frequent avoidance 2

Severe, much avoidance. Greater than 3 up to 8 hr/day. Very frequent avoidance. 3

Extreme very extensive avoidance. Greater than 8 hr/day. Doing almost everything
4
you can to avoid triggering symptoms.

Finally:
What would be the worst thing that could happen (to you) if you were not able to avoid
the misophonic triggers?
Describe

*Amsterstam Misophonia Scale (A-MISO-S) from Schröder, A., Vulink, N., & Denys, S. (2013). Misophonia:
Diagnostic criteria for a new psychiatric disorder. PLoS ONE, 8(1), e54706. doi:10.1371/journal.pone.0054706
Name: __________________________________ Date: _______________

Misophonia Impact Survey

1. Rate how misophonia has interfered with family life in the past 2 weeks. (If you have avoided
these activities because of misophonia, include that factor in your rating.)

None Mildly Moderately Severely Extremely Not-applicable

0 1 2 3 4 5 6 7 8 9 10 N/A

2. Rate how misophonia has interfered with intimate relationships in the past 2 weeks. (If you
have avoided this because of misophonia, include that factor in your rating.)

None Mildly Moderately Severely Extremely Not-applicable

0 1 2 3 4 5 6 7 8 9 10 N/A

3. Rate how misophonia has interfered with your social life and leisure activities with others in
the past 2 weeks. (If you avoid these activities because of misophonia include that factor in
your rating.)

None Mildly Moderately Severely Extremely Not-applicable

0 1 2 3 4 5 6 7 8 9 10 N/A

4. Rate how misophonia has interfered with your work / school work, including unpaid
volunteer work, training, or similar activities in the past 2 weeks. (If you avoid these activities
because of misophonia include that factor in your rating.)

None Mildly Moderately Severely Extremely Not-applicable

0 1 2 3 4 5 6 7 8 9 10 N/A

5. Rate how misophonia has interfered with your individual activities and alone time in the past
2 weeks. (If you avoid certain activities because of misophonia include that factor in your
rating.)

None Mildly Moderately Severely Extremely Not-applicable

0 1 2 3 4 5 6 7 8 9 10 N/A

Version 1.0, Misophonia Institute

Misophonia Activation Scale
(MAS-1) from www.misophonia-UK.org Name: ___________________________________ Date: _________
Please select the level that best describes what you experience.

Part A: Emotional Response

0☐ I hear a known trigger sound but feel no discomfort.
I am aware of the presence of a known trigger person but feel no, or minimal, anticipatory
1☐ anxiety.
Known trigger sounds elicit minimal psychic discomfort, irritation, or annoyance. No symptoms of
2☐ panic or fight or flight response.
I feel increasing levels of psychic discomfort but do not engage in any physical response. I may be
3☐ hyper-vigilant to audio-visual stimuli.
I engage in a minimal physical response – non-confrontational coping behaviors, such as asking
4☐ 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.
I adopt more confrontational coping mechanisms, such as overtly covering my ears, mimicking the
5☐ trigger person, make repeated sounds, or display overt irritation.
I experience substantial psychic discomfort. Symptoms of panic and a fight or flight response
6☐ begin to engage.
I experience substantial psychic discomfort. Increasing use (louder, more frequent) use of
7☐ 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.
Panic/rage reaction in full swing. Conscious decision not to use violence on trigger person. Actual
9☐ 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.
Actual use of physical violence on a person or animal (i.e., a household pet). Violence may be
10 ☐ inflicted on self (self-harming).

Part B: Physical Sensation

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 pain

Version: 06-19-14
Detailed Trigger Inventory - Misophonia Activation Scale
Name: _______________________________________________ Date: ________________
Please list all your triggers. Several triggers or sources can be listed together if they have the same ratings.

Emotional Physical
Trigger Sound/Sight Source (person)
Response Sensation
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30

Version: 07-30-14
Part A: Emotional Response*
0 I hear a known trigger sound but feel no discomfort.
I am aware of the presence of a known trigger person but feel no, or minimal, anticipatory
1
anxiety.
Known trigger sounds elicit minimal psychic discomfort, irritation, or annoyance. No symptoms of
2
panic or fight or flight response.
I feel increasing levels of psychic discomfort but do not engage in any physical response. I may be
3
hyper-vigilant to audio-visual stimuli.
I engage in a minimal physical response – non-confrontational coping behaviors, such as asking
4 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.
I adopt more confrontational coping mechanisms, such as overtly covering my ears, mimicking the
5
trigger person, make repeated sounds, or display overt irritation.
I experience substantial psychic discomfort. Symptoms of panic and a fight or flight response
6
begin to engage.
I experience substantial psychic discomfort. Increasing use (louder, more frequent) use of
7 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.
Panic/rage reaction in full swing. Conscious decision not to use violence on trigger person. Actual
9 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.
Actual use of physical violence on a person or animal (i.e., a household pet). Violence may be
10
inflicted on self (self-harming).
*MAS-1 from www.misophonia-UK.org
Part B: Physical Sensation
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 pain

Version: 07-30-14
Name: _________________________ Date: _________

Misophonia Coping Responses

Please rate your use of the following coping responses to your trigger sounds.

RATING SCALE:
0 = not at all, 1 = a little of the time, 2 = a good deal of the time, 3 = almost all the time
0 1 2 3
1. You hear a known trigger sound. You may dislike the sound but you feel
no physical sensation.
2. You hear a trigger sound and feel annoyed or upset, but no coping
response.
3. Facial or bodily responses that show you are annoyed

4. Facial or bodily responses that show you are upset

5. You turn away or cover your eyes so you don’t see the person

6. Put on headphones

7. Calmly move away from the sound

8. Discreetly cover one or both ears

9. Mimic the person who makes the trigger sound

10. Repeat words or sounds

11. Overtly cover your ears

12. Nicely ask the person to stop making the sound.

13. Sternly or harshly ask the person to stop making the sound.

14. Tell/order the person to stop making the sound.

15. You push, poke, shove, etc. the person making the sound.

16. You verbally snap at the person making the sound.

17. Leave the room after attempting to tolerate the sound

18. Immediately leave the room to escape the sound

19. Verbal assault of the person making the noise

20. Scream or cry loudly

21. Actual use of physical violence on another person, animal, or self.

Revised: 05/01/13
Name: _________________________ Date: _________
Misophonia Emotional Responses Please rate how often you feel the
following emotional responses to your trigger sounds. This is what you feel, not what you actually do.
RATING SCALE:
0 1 2 3
0 = not at all, 1 = a little of the time, 2 = a good deal of the time, 3 = almost all the time
1. You hear a known trigger sound. You may dislike the sound.
2. You hear a trigger sound and feel annoyed or upset.
3. You want the other person to know how upset you are.
4. You want the person to stop making the sound.
5. You want to force the other person to stop making the sound.
6. You feel you must see that the person is actually making the sound or
doing what you think they are doing. You want to keep looking or stare.
7. You want to hear something else, so you don’t hear the sound.
8. You want to be physically far away from the sound.
9. You wish you were deaf.
10. You are afraid that if you do something, you will hurt others feelings.
11. You want to get away from the sound, but do not want to make a scene.
12. You want to get away from the sound as quickly as possible, even if it
would be embarrassing.
13. You want to push, poke, shove, etc. the person making the sound.
14. You want to verbally assault of the person making the noise.
15. You want to physically assault the person making the noise.
16. You want to physically hurt or harm the other person.
17. You want to scream or cry loudly.
18. You feel anger.
19. You feel rage.
20. You hate the person.
21. You feel disgust.
22. You feel resentment.
23. You feel you need to escape, flee, or run away.
24. You want to get revenge.
25. You feel offended by the person making the noise.
26. You feel despair or hopeless.
27. You feel guilt regarding what you thought.
28. You feel guilt regarding what you did when triggered.
29. You fear that more triggers will occur.
30. You feel fear when you hear a trigger.
Describe other emotions and feelings you experience when triggered.

Revised: 01/31/17
 MisophoniaTreatment.com

Misophonia History Questionnaire for Patients

Name: ________________________________________________ Date: ____________

1. Age: ______ Sex: _______

2. When did you first experience misophonia? (your age or the date) ________________________

3. What was your first trigger? ________________________________________________________

4. Describe the situation and significant life events happening when you acquired the first trigger?

5. At what age did your misophonia become severe? _____________________________________

6. List your trigger sounds.

7. List any visual triggers.

8. List any odor, touch, vibration, taste, or other triggers.

9. What emotional reactions to you usually have when you are triggered? (such as I feel anger and it makes
me want to punch someone in the face, or I feel disgust and I feel like I have to leave the room or I will die.)

version 7
 MisophoniaTreatment.com

10. Do you feel a physical response to a trigger sound?

If so, what do you feel? (such as shoulder muscles tightens, jaw jerks, nausea, or stomach knots up)

11. List any patters you have identified in relation to your misophonia, both general or specific. This may
include times of day, your physical conditions such as fatigue, hunger, etc., or emotional conditions.

12. Please describe how Misophonia has affected your life, for example, psychologically, emotionally, your
relationships, work, social life, or in ANY way.

13. List any tendencies (or conditions) you have (obsessive/compulsive behavior, anxiety, ADD, etc.):

14. What is your employment or school situation and does your misophonia cause a problem in that setting?

15. Do you have an iPhone/iPad? __________ Android phone/tablet? __________ None? _______

version 7
Patient Information for Sequent Repatterning Therapy for Misophonia Treatment

Full name: ________________________________________________________ Date: ______________

Home address

Street: ________________________________________________________________________________

City: __________________________________________________________________________________

State/Province: _________________________________________________________________________

Country: ______________________________________________________________________________

Postal Code: ___________________________________________________________________________

Telephone number: _____________________________________________________________________

Can a confidential message be left on this number? (Y/N) _______

email address: __________________________________________________________________________

Can a confidential message be sent to this address? (Y/N) _______

Date of birth: ___________________________________________________________________________

Family
Mother's name: ______________________________________________________________________

Father's name: _______________________________________________________________________

Siblings' ages and names:

_______________________________________________________________

Partner's name: ______________________________________________________________________

Children( name and age):

_______________________________________________________________

Occupation: ___________________________________________________________________________

Diagnosed medical conditions: ____________________________________________________________

Current medication: _____________________________________________________________________

Any allergies: __________________________________________________________________________