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Questionnaire template

Everyday Detachment Experiences Self-Reflection

A non-diagnostic reflection for adults on how often they have memory gaps, absorption or feelings of detachment.

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Healthcare · Mental health assessment. All Healthcare templates

Questions in this template

Everyday Lapses

  1. Thank you for taking part. These questions ask about moments of absorption, memory gaps or feeling detached that many people have from time to time. This is a reflection exercise, not a diagnosis.

  2. How often do you suddenly realise you cannot recall what you were doing for the past few minutes?

    Choose one:

    • Never
    • Rarely
    • Sometimes
    • Often
    • Very often

  3. How often do you arrive somewhere without remembering how you got there?

    Choose one from a list:

    • Never
    • Rarely
    • Sometimes
    • Often
    • Very often

Feeling Unfamiliar or Unreal

  1. Has each of the following ever happened to you?

    • Familiar people or surroundings suddenly seemed strange to me
    • The people and things around me felt distant or not quite real
    • I behaved in a way that felt very unlike my usual self
    • Others told me about something I had done that I could not remember

    For each row: choose one:

    • Yes
    • Not sure
    • No

Memory and Self-Observation

  1. How often are you unsure whether something you remember really happened or was only a dream?

    Choose one:

    • Never
    • Rarely
    • Sometimes
    • Often
    • Very often

  2. When you are with other people, how often do you feel as if you are watching yourself from the outside?

    Choose one:

    • Never
    • Rarely
    • Sometimes
    • Often
    • Very often

Anything Else

  1. Can you describe a time when your behaviour surprised you because it felt so unlike you? (optional)

    Condition: Shown when acting unlike oneself has happened

    Open answer

  2. Have you had any other experiences of feeling detached from yourself or your surroundings that we have not asked about? Please describe them. (optional)

    Open answer

  3. If any of these experiences are frequent or upsetting, consider talking to a doctor or a mental health professional.