For each statement, select the response that seems to describe your child for the past 3 months
When my child feels frightened, it is hard for them to breathe.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
My child gets headaches when they are at school.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
My child doesn’t like to be with people they don't know well.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
My child gets scared if they sleep away from home.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
My child worries about other people liking them.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
When my child gets frightened, they feel like passing out.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
My child is nervous.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
My child follows me wherever I go.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
People tell me that my child looks nervous.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
My child feels nervous with people they don't know well.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
My child gets stomachaches at school.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
When my child gets frightened, they feel like they are going crazy.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
My child worries about sleeping alone.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
My child worries about being as good as other kids.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
When my child gets frightened, they feel like things are not real.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
My child has nightmares about something bad happening to their parents.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
My child worries about going to school.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
When my child gets frightened, their heart beats fast.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
My child gets shaky.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
My child has nightmares about something bad happening to them.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
My child worries about things working out for them.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
When my child gets frightened, they sweat a lot.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
My child is a worrier.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
My child gets really frightened for no reason at all.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
My child is afraid to be alone in the house.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
It is hard for my child to talk with people they don't know well.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
When my child gets frightened, they feel like they are choking.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
People tell my child that they worry too much.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
My child does not like to be away from their family.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
My child is afraid of having anxiety (or panic) attacks.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
My child worries that something bad might happen to their parents.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
My child feels shy with people they don't know well.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
My child worries about what is going to happen in the future.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
When my child feels frightened, they feel like throwing up.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
My child worries about how well they do things.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
My child is scared to go to school.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
My child worries about things that have already happened.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
When my child gets frightened, they feel dizzy.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
My child feels nervous when they are with other children or adults and they have to do something while being watched (for example: read aloud, speak, play a game, play a sport).
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
My child feels nervous when they are going to parties, dances or any place where there will be people that they don't know well.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
My child is shy.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
