Name* First Last Date* Directions: Below is a list of sentences that describe how people feel. Read each phrase and decide if it is “Not True or Hardly Ever True” or “Somewhat True or Sometimes True” or “Very True or Often True” for you. Then, for each sentence, fill in one circle that corresponds to the response that seems to describe you for the last 3 months. When I feel frightened, it is hard to breathe*SelectNot True or Hardly Ever TrueSomewhat True or Sometimes TrueVery True or Often TrueI get headaches when I am at school*SelectNot True or Hardly Ever TrueSomewhat True or Sometimes TrueVery True or Often TrueI don’t like to be with people I don’t know well*SelectNot True or Hardly Ever TrueSomewhat True or Sometimes TrueVery True or Often TrueI get scared if I sleep away from home*SelectNot True or Hardly Ever TrueSomewhat True or Sometimes TrueVery True or Often TrueI worry about other people liking me*SelectNot True or Hardly Ever TrueSomewhat True or Sometimes TrueVery True or Often TrueWhen I get frightened, I feel like passing out*SelectNot True or Hardly Ever TrueSomewhat True or Sometimes TrueVery True or Often TrueI am nervous*SelectNot True or Hardly Ever TrueSomewhat True or Sometimes TrueVery True or Often TrueI follow my mother or father wherever they go*SelectNot True or Hardly Ever TrueSomewhat True or Sometimes TrueVery True or Often TruePeople tell me that I look nervous*SelectNot True or Hardly Ever TrueSomewhat True or Sometimes TrueVery True or Often TrueI feel nervous with people I don’t know well*SelectNot True or Hardly Ever TrueSomewhat True or Sometimes TrueVery True or Often TrueI get stomachaches at school*SelectNot True or Hardly Ever TrueSomewhat True or Sometimes TrueVery True or Often TrueWhen I get frightened, I feel like I am going crazy*SelectNot True or Hardly Ever TrueSomewhat True or Sometimes TrueVery True or Often TrueI worry about sleeping alone*SelectNot True or Hardly Ever TrueSomewhat True or Sometimes TrueVery True or Often TrueI worry about being as good as other kids*SelectNot True or Hardly Ever TrueSomewhat True or Sometimes TrueVery True or Often TrueWhen I get frightened, I feel like things are not real*SelectNot True or Hardly Ever TrueSomewhat True or Sometimes TrueVery True or Often TrueI have nightmares about something bad happening to my parents*SelectNot True or Hardly Ever TrueSomewhat True or Sometimes TrueVery True or Often TrueI worry about going to school*SelectNot True or Hardly Ever TrueSomewhat True or Sometimes TrueVery True or Often TrueWhen I get frightened, my heart beats fast*SelectNot True or Hardly Ever TrueSomewhat True or Sometimes TrueVery True or Often TrueI get shaky*SelectNot True or Hardly Ever TrueSomewhat True or Sometimes TrueVery True or Often TrueI have nightmares about something bad happening to me*SelectNot True or Hardly Ever TrueSomewhat True or Sometimes TrueVery True or Often TrueI worry about things working out for me*SelectNot True or Hardly Ever TrueSomewhat True or Sometimes TrueVery True or Often TrueWhen I get frightened, I sweat a lot*SelectNot True or Hardly Ever TrueSomewhat True or Sometimes TrueVery True or Often TrueI am a worrier*SelectNot True or Hardly Ever TrueSomewhat True or Sometimes TrueVery True or Often TrueI get really frightened for no reason at all*SelectNot True or Hardly Ever TrueSomewhat True or Sometimes TrueVery True or Often TrueI am afraid to be alone in the house*SelectNot True or Hardly Ever TrueSomewhat True or Sometimes TrueVery True or Often TrueIt is hard for me to talk with people I don’t know well*SelectNot True or Hardly Ever TrueSomewhat True or Sometimes TrueVery True or Often TrueWhen I get frightened, I feel like I am choking*SelectNot True or Hardly Ever TrueSomewhat True or Sometimes TrueVery True or Often TruePeople tell me that I worry too much*SelectNot True or Hardly Ever TrueSomewhat True or Sometimes TrueVery True or Often TrueI don’t like to be away from my family*SelectNot True or Hardly Ever TrueSomewhat True or Sometimes TrueVery True or Often TrueI am afraid of having anxiety (or panic) attacks*SelectNot True or Hardly Ever TrueSomewhat True or Sometimes TrueVery True or Often TrueI worry that something bad might happen to my parents*SelectNot True or Hardly Ever TrueSomewhat True or Sometimes TrueVery True or Often TrueI feel shy with people I don’t know well*SelectNot True or Hardly Ever TrueSomewhat True or Sometimes TrueVery True or Often TrueI worry about what is going to happen in the future*SelectNot True or Hardly Ever TrueSomewhat True or Sometimes TrueVery True or Often TrueWhen I get frightened, I feel like throwing up*SelectNot True or Hardly Ever TrueSomewhat True or Sometimes TrueVery True or Often TrueI worry about how well I do things*SelectNot True or Hardly Ever TrueSomewhat True or Sometimes TrueVery True or Often TrueI am scared to go to school*SelectNot True or Hardly Ever TrueSomewhat True or Sometimes TrueVery True or Often TrueI worry about things that have already happened*SelectNot True or Hardly Ever TrueSomewhat True or Sometimes TrueVery True or Often TrueWhen I get frightened, I feel dizzy*SelectNot True or Hardly Ever TrueSomewhat True or Sometimes TrueVery True or Often TrueI feel nervous when I am with other children or adults and I have to do something while they watch me (for example: read aloud, speak, play a game, play a sport)*SelectNot True or Hardly Ever TrueSomewhat True or Sometimes TrueVery True or Often TrueI feel nervous when I am going to parties, dances, or any place where there will be people that I don’t know well*SelectNot True or Hardly Ever TrueSomewhat True or Sometimes TrueVery True or Often TrueI am shy*SelectNot True or Hardly Ever TrueSomewhat True or Sometimes TrueVery True or Often TrueTotal Score (A total score of ≥ 25 may indicate the presence of an Anxiety Disorder. Scores higher than 30 are more specific.)Panic or Somatic Disorders (A score of 7 for these items may indicate Panic Disorder or Significant Somatic Symptoms.)Generalized Anxiety Disorder (A score of 9 for items may indicate Generalized Anxiety Disorder. )Separation Anxiety SOC (A score of 5 for items may indicate Separation Anxiety SOC.)Social Anxiety Disorder (A score of 8 for items may indicate Social Anxiety Disorder.)Significant School Avoidance (A score of 3 for items may indicate Significant School Avoidance.)