Name: Pediatric People
Price range: $

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

Not true or hardly ever true

Somewhat true or sometimes true

Very true or often true

2. My child gets headaches when he/she is at school.

Not true or hardly ever true

Somewhat true or sometimes true

Very true or often true

3. My child doesn’t like to be with people he/she doesn’t know well.

Not true or hardly ever true

Somewhat true or sometimes true

Very true or often true

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

Not true or hardly ever true

Somewhat true or sometimes true

Very true or often true

5. My child worries about other people liking him/her.

Not true or hardly ever true

Somewhat true or sometimes true

Very true or often true

6. When my child gets frightened, he/she feels like passing out.

Not true or hardly ever true

Somewhat true or sometimes true

Very true or often true

7. My child is nervous.

Not true or hardly ever true

Somewhat true or sometimes true

Very true or often true

8. My child follows me wherever I go.

Not true or hardly ever true

Somewhat true or sometimes true

Very true or often true

9. People tell me that my child looks nervous.

Not true or hardly ever true

Somewhat true or sometimes true

Very true or often true

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

Not true or hardly ever true

Somewhat true or sometimes true

Very true or often true

11. My child gets stomachaches at school.

Not true or hardly ever true

Somewhat true or sometimes true

Very true or often true

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

Not true or hardly ever true

Somewhat true or sometimes true

Very true or often true

13. My child worries about sleeping alone.

Not true or hardly ever true

Somewhat true or sometimes true

Very true or often true

14. My child worries about being as good as other kids.

Not true or hardly ever true

Somewhat true or sometimes true

Very true or often true

15. When he/she gets frightened, he/she feels like things are not real.

Not true or hardly ever true

Somewhat true or sometimes true

Very true or often true

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

Not true or hardly ever true

Somewhat true or sometimes true

Very true or often true

17. My child worries about going to school.

Not true or hardly ever true

Somewhat true or sometimes true

Very true or often true

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

Not true or hardly ever true

Somewhat true or sometimes true

Very true or often true

19. He/she gets shaky.

Not true or hardly ever true

Somewhat true or sometimes true

Very true or often true

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

Not true or hardly ever true

Somewhat true or sometimes true

Very true or often true

21. My child worries about things working out for him/her.

Not true or hardly ever true

Somewhat true or sometimes true

Very true or often true

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

Not true or hardly ever true

Somewhat true or sometimes true

Very true or often true

23. My child is a worrier.

Not true or hardly ever true

Somewhat true or sometimes true

Very true or often true

24. My child gets really frightened for no reason at all.

Not true or hardly ever true

Somewhat true or sometimes true

Very true or often true

25. My child is afraid to be alone in the house.

Not true or hardly ever true

Somewhat true or sometimes true

Very true or often true

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

Not true or hardly ever true

Somewhat true or sometimes true

Very true or often true

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

Not true or hardly ever true

Somewhat true or sometimes true

Very true or often true

28. People tell me that my child worries too much.

Not true or hardly ever true

Somewhat true or sometimes true

Very true or often true

29. My child doesn’t like to be away from his/her family.

Not true or hardly ever true

Somewhat true or sometimes true

Very true or often true

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

Not true or hardly ever true

Somewhat true or sometimes true

Very true or often true

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

Not true or hardly ever true

Somewhat true or sometimes true

Very true or often true

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

Not true or hardly ever true

Somewhat true or sometimes true

Very true or often true

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

Not true or hardly ever true

Somewhat true or sometimes true

Very true or often true

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

Not true or hardly ever true

Somewhat true or sometimes true

Very true or often true

35. My child worries about how well he/she does things.

Not true or hardly ever true

Somewhat true or sometimes true

Very true or often true

36. My child is scared to go to school.

Not true or hardly ever true

Somewhat true or sometimes true

Very true or often true

37. My child worries about things that have already happened.

Not true or hardly ever true

Somewhat true or sometimes true

Very true or often true

38. When my child gets frightened, he/she feels dizzy.

Not true or hardly ever true

Somewhat true or sometimes true

Very true or often true

39. 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.)

Not true or hardly ever true

Somewhat true or sometimes true

Very true or often true

40. My child feels nervous when he/she is going to parties, dances, or any place where there will be people that he/she doesn’t know well.

Not true or hardly ever true

Somewhat true or sometimes true

Very true or often true

41. My child is shy.

Not true or hardly ever true

Somewhat true or sometimes true

Very true or often true

Patient's Name(Required)

First Last

Date of Birth(Required)

Form Completed By(Required)

First Last

Relationship To Patient(Required)

Mother

Father

Other

Hidden

Total

A total score of ≥ 25 may indicate the presence of an Anxiety Disorder. Scores higher than 30 are more specific.

Hidden

Panic Disorder or Significant Somatic Symptoms

A score of 7 for items 1, 6, 9, 12, 15, 18, 19, 22, 24, 27, 30, 34, 38 may indicate Panic Disorder or Significant Somatic Symptoms.

Hidden

Generalized Anxiety Disorder

A score of 9 for items 5, 7, 14, 21, 23, 28, 33, 35, 37 may indicate Generalized Anxiety Disorder.

Hidden

Separation Anxiety Disorder

A score of 5 for items 4, 8, 13, 16, 20, 25, 29, 31 may indicate Separation Anxiety Disorder.

Hidden

Significant School Avoidance

A score of 3 for items 2, 11, 17, 36 may indicate Significant School Avoidance.

Hidden

Social Anxiety Disorder

A score of 8 for items 3, 10, 26, 32, 39, 40, 41 may indicate Social Anxiety Disorder.

SCARED ASSESSMENT