Please answer the following questions with the choice that seems to describe you/your child for the past 3 months .
When I feel frightened, it is hard to breathe.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
I get headaches when I am at school.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
I don't like to be with people I don't know well.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
I get scared if I sleep away from home.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
I worry about other people liking me.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
When I get frightened, I feel like passing out.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
I am nervous.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
I follow my mother or father wherever they 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 I look nervous.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
I feel nervous with people I don't know well.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
I get stomachaches at school.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
When I get frightened, I feel like I am going crazy.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
I worry about sleeping alone.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
I worry 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 I get frightened, I 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
I have nightmares about something bad happening to my parents.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
I worry 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 I get frightened, my heart beats fast.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
I get shaky.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
I have nightmares about something bad happening to me.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
I worry about things working out for me.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
When I get frightened, I sweat a lot.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
I am a worrier.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
I get 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
I am 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 me to talk with people I 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 I get frightened, I feel like I am choking.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
People tell me that I worry too much.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
I don't like to be away from my family.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
I am 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
I worry that something bad might happen to my parents.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
I feel shy with people I don't know well.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
I worry 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 I feel frightened, I feel like throwing up.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
I worry about how well I do things.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
I am 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
I worry 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 I get frightened, I feel dizzy.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
I 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).
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
I feel nervous when I am going to parties, dances or any place where there will be people that I don't know well.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
I am shy.
Please select your answer
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
