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ADMIN – SCARED ASSESSMENT
Michael
2023-06-19T09:43:53-05:00
SCARED ASSESSMENT
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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
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First
Last
Date of Birth
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Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
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11
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15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
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1920
Form Completed By
*
First
Last
Relationship To Patient
*
Select One
Mother
Father
Other
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Total
A total score of ≥ 25 may indicate the presence of an Anxiety Disorder. Scores higher than 30 are more specific.
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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.
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Generalized Anxiety Disorder
A score of 9 for items 5, 7, 14, 21, 23, 28, 33, 35, 37 may indicate Generalized Anxiety Disorder.
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Separation Anxiety Disorder
A score of 5 for items 4, 8, 13, 16, 20, 25, 29, 31 may indicate Separation Anxiety Disorder.
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Significant School Avoidance
A score of 3 for items 2, 11, 17, 36 may indicate Significant School Avoidance.
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Social Anxiety Disorder
A score of 8 for items 3, 10, 26, 32, 39, 40, 41 may indicate Social Anxiety Disorder.
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