| Name: Age: Sex: |
| Educational Level: Occupation: Date: |
| (Mark correct answers with an X) |
| 1 - How long have you have a mobile phone (MP)? |
| A- Less than 1 year; B- 1 to 2 years; C- 3 to 4 years; D- More than 4 years |
| 2-Do you routinely use an MP all day? YES/NO |
| 3 - Can you leave home without taking your MP? YES/NO |
| 4-When you forget your MP, do you come back for it? YES/NO |
| 5 - Do you feel anxious when you forget your MP? A- No; B-Yes, between 10% and 30%; C-Yes, between 30% and 50%; D-Yes, between 50% and 70%; E-Yes, between 70% and 90%; F-Yes, 100% anxious |
| 6 - How far can you travel from your home without an MP? A- 500 m; B- 1 km; C-More than 1 km |
| 7 – Do you make more than three calls per day? YES/NO |
| 8- Do you receive more than three calls per day? YES/NO |
| 9 - Do you often feel rejected when no one calls you? YES/NO |
| 10 - Do you feel low self-esteem when you see that your friend has received more calls than you? YES/NO |
| 11 - Do you like to be found at any time? YES/NO |
| 12 – Do you turn off your MP in restaurants or in the company of another person? YES/NO |
| 13 – Do you set your MP to vibrate rather than turning it off? YES/NO |
| 14 – Do you keep your MP on 24 hours a day? YES/NO |
| 15 - Do you sleep with your MP turned on? YES/NO |
| 16- Have you experienced any of the following symptoms or emotions due to not having your MP near? A- Tachycardia; B- Tremors; C- Sweating; D- Changes in respiration; E- Depression; F- Loneliness; G- Rejection; H- Panic |
| 17- Are you afraid of feeling ill in public and not having an MP to call in an emergency? YES/NO |
| 18 - Do you have your doctor’s phone number on speed dial? YES/NO |
| 19 - Do you have your hospital’s phone number on speed dial? YES/NO |
| 20 - Do you have your psychologist’s phone number on speed dial? YES/NO |
| 21 - Before you go to sleep, do you usually call someone to retain his or her phone number in the MP’s immediate memory to call if you feel bad? YES/NO |
| 22 - Do you feel comforted by having immediate access to others whenever you want? |
| YES/NO |
| 23 - Would you lend your MP to a friend for a week? YES/NO |
| 24- How do you feel when your MP has no minutes, battery charge, or is out of range? A- Anxious; B- distressed; C- Agitated; D- Afraid; E- Disoriented |
| 25 – When you have your MP, do you feel monitored 24 hours a day? YES/NO |
| 26 - Do you feel dependent on your MP? YES/NO |
| 27 - Do you feel insecure without your MP? A- NO; B- Yes, between 10% and 30%; C- Yes, between 30% and 50%; D- Yes, between 50% and 70%; E- Yes, between 70% and 90%; F-Yes, 100% insecure |
| 28 – Do you have the feeling of being with someone when you have your MP? YES/NO |
| 29 – Would you feel you had the same freedom of movement if you were without your MP? YES/NO |