Your Clinician*

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 your child. Then, for each statement, fill in one circle that corresponds to the response that seems to describe your child for the last 3 months. Please respond to all statements as well as you can, even if some do not seem to concern your child.

When my child feels frightened, it is hard for him/her to breathe*

My child gets headaches when he/she am at school*

My child doesn’t like to be with people he/she does't know well*

My child gets scared if he/she sleeps away from home*

My child worries about other people liking him/her*

When my child gets frightened, he/she fells like passing out*

My child is nervous*

My child follows me wherever I go*

People tell me that my child looks nervous*

My child feels nervous with people he/she doesn’t know well*

My child gets stomachaches at school*

When my child gets frightened, he/she feels like he/she is going crazy*

My child worries about sleeping alone*

My child worries about being as good as other kids*

When my child gets frightened, he/she feels like things are not real*

My child has nightmares about something bad happening to his/her parents*

My child worries about going to school*

When my child gets frightened, his/her heart beats fast*

He/she child gets shaky*

My child has nightmares about something bad happening to him/her*

My child worries about things working out for him/her*

When my child gets frightened, he/she sweats a lot*

My child is a worrier*

My child gets really frightened for no reason at all*

My child is afraid to be alone in the house*

It is hard for my child to talk with people he/she doesn’t know well*

When my child gets frightened, he/she feels like he/she is choking*

People tell me that my child worries too much*

My child doesn't like to be away from his/her family*

My child is afraid of having anxiety (or panic) attacks*

My child worries that something bad might happen to his/her parents*

My child feels shy with people he/she doesn’t know well*

My child worries about what is going to happen in the future*

When my child gets frightened, he/she feels like throwing up*

My child worries about how well he/she does things*

My child is scared to go to school*

My child worries about things that have already happened*

When my child gets frightened, he/she feels dizzy*

My child feels nervous when he/she is with other children or adults and he/she has to do something while they watch him/her (for example: read aloud, speak, play a game, play a sport)*

My child is shy*

Total 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.)