How much fear or anxiety do you feel talking to classmates or others on a telephone?
Please select your answer
None
Mild
Moderate
Severe
How often do you avoid talking to classmates or others on a telephone?
Please select your answer
Never
Occasionally
Often
Usually
How much fear or anxiety do you feel participating in work groups in the classroom?
Please select your answer
None
Mild
Moderate
Severe
How often do you avoid participating in work groups in the classroom?
Please select your answer
Never
Occasionally
Often
Usually
How much fear or anxiety do you feel eating in front of others (e.g. school, cafeteria, restaurants)?
Please select your answer
None
Mild
Moderate
Severe
How often do you avoid eating in front of others (e.g. school, cafeteria, restaurants)?
Please select your answer
Never
Occasionally
Often
Usually
How much fear or anxiety do you feel asking an adult you don't know well, like a store clerk, principal or policeman for help (e.g. for directions or to explain something that you don't understand)?
Please select your answer
None
Mild
Moderate
Severe
How often do you avoid asking an adult you don't know well, like a store clerk, principal or policeman for help (e.g. for directions or to explain something that you don't understand)?
Please select your answer
Never
Occasionally
Often
Usually
How much fear or anxiety do you feel giving a verbal report or presentation in class (e.g. show and tell for younger children)?
Please select your answer
None
Mild
Moderate
Severe
How often do you avoid giving a verbal report or presentation in class (e.g. show and tell for younger children)?
Please select your answer
Never
Occasionally
Often
Usually
How much fear or anxiety do you feel going to parties, dances or school activities?
Please select your answer
None
Mild
Moderate
Severe
How often do you avoid going to parties, dances or school activities?
Please select your answer
Never
Occasionally
Often
Usually
How much fear or anxiety do you feel writing on the chalkboard or in front of others?
Please select your answer
None
Mild
Moderate
Severe
How often do you avoid writing on the chalkboard or in front of others?
Please select your answer
Never
Occasionally
Often
Usually
How much fear or anxiety do you feel talking with other kids you don't know well?
Please select your answer
None
Mild
Moderate
Severe
How often do you avoid talking with other kids you don't know well?
Please select your answer
Never
Occasionally
Often
Usually
How much fear or anxiety do you feel starting a conversation with people you don't know well?
Please select your answer
None
Mild
Moderate
Severe
How often do you avoid starting a conversation with people you don't know well?
Please select your answer
Never
Occasionally
Often
Usually
How much fear or anxiety do you feel using school or public bathrooms?
Please select your answer
None
Mild
Moderate
Severe
How often do you avoid using school or public bathrooms?
Please select your answer
Never
Occasionally
Often
Usually
How much fear or anxiety do you feel going into a classroom or another place (e.g. church, cafeteria, food court) when others are already seated?
Please select your answer
None
Mild
Moderate
Severe
How often do you avoid going into a classroom or another place (e.g. church, cafeteria, food court) when others are already seated?
Please select your answer
Never
Occasionally
Often
Usually
How much fear or anxiety do you feel having people pay close attention to you, or being the center of attention (e.g. your own birthday party)?
Please select your answer
None
Mild
Moderate
Severe
How often do you avoid having people pay close attention to you, or being the center of attention (e.g. your own birthday party)?
Please select your answer
Never
Occasionally
Often
Usually
How much fear or anxiety do you feel asking questions in class?
Please select your answer
None
Mild
Moderate
Severe
How often do you avoid asking questions in class?
Please select your answer
Never
Occasionally
Often
Usually
How much fear or anxiety do you feel answering questions in class?
Please select your answer
None
Mild
Moderate
Severe
How often do you avoid answering questions in class?
Please select your answer
Never
Occasionally
Often
Usually
How much fear or anxiety do you feel reading out loud in class?
Please select your answer
None
Mild
Moderate
Severe
How often do you avoid reading out loud in class?
Please select your answer
Never
Occasionally
Often
Usually
How much fear or anxiety do you feel taking a test?
Please select your answer
None
Mild
Moderate
Severe
How often do you avoid taking a test?
Please select your answer
Never
Occasionally
Often
Usually
How much fear or anxiety do you feel saying 'no' to others when they ask you to do something that you don't want to do (like borrow something or look at your homework)?
Please select your answer
None
Mild
Moderate
Severe
How often do you avoid saying 'no' to others when they ask you to do something that you don't want to do (like borrow something or look at your homework)?
Please select your answer
Never
Occasionally
Often
Usually
How much fear or anxiety do you feel telling others that you disagree or that you are angry with them?
Please select your answer
None
Mild
Moderate
Severe
How often do you avoid telling others that you disagree or that you are angry with them?
Please select your answer
Never
Occasionally
Often
Usually
How much fear or anxiety do you feel looking at people you don't know well in the eyes?
Please select your answer
None
Mild
Moderate
Severe
How often do you avoid looking at people you don't know well in the eyes?
Please select your answer
Never
Occasionally
Often
Usually
How much fear or anxiety do you feel returning something in a store?
Please select your answer
None
Mild
Moderate
Severe
How often do you avoid returning something in a store?
Please select your answer
Never
Occasionally
Often
Usually
How much fear or anxiety do you feel playing a sport or performing in front of other people (e.g. gym class, dance school recital, musical concert)?
Please select your answer
None
Mild
Moderate
Severe
How often do you avoid playing a sport or performing in front of other people (e.g. gym class, dance school recital, musical concert)?
Please select your answer
Never
Occasionally
Often
Usually
How much fear or anxiety do you feel joining a club or organization?
Please select your answer
None
Mild
Moderate
Severe
How often do you avoid joining a club or organization?
Please select your answer
Never
Occasionally
Often
Usually
How much fear or anxiety do you feel meeting new people or strangers?
Please select your answer
None
Mild
Moderate
Severe
How often do you avoid meeting new people or strangers?
Please select your answer
Never
Occasionally
Often
Usually
How much fear or anxiety do you feel asking a teacher permission to leave the classroom (e.g. to go to the bathroom or the nurse)?
Please select your answer
None
Mild
Moderate
Severe
How often do you avoid asking a teacher permission to leave the classroom (e.g. to go to the bathroom or the nurse)?
Please select your answer
Never
Occasionally
Often
Usually
