Directions: Below is a list of sentences that describe how people feel. Read each phrase and decide if it is “Not True or Hardly Ever True” or “Somewhat True or Sometimes True” or “Very True or Often True” for you. Then for each sentence, fill in one circle that corresponds to the response that seems to describe you for the last 3 months.

1. When I feel frightened, it is hard to breathe. *

0 Not True or Hardly Ever True

1 Somewhat True or Sometimes True

2 Very True or Often True

2. I get headaches when I am at school. *

0 Not True or Hardly Ever True

1 Somewhat True or Sometimes True

2 Very True or Often True

3. I don’t like to be with people I don’t know well. *

0 Not True or Hardly Ever True

1 Somewhat True or Sometimes True

2 Very True or Often True

4. I get scared if I sleep away from home. *

0 Not True or Hardly Ever True

1 Somewhat True or Sometimes True

2 Very True or Often True

5. I worry about other people liking me. *

0 Not True or Hardly Ever True

1 Somewhat True or Sometimes True

2 Very True or Often True

6. When I get frightened, I feel like passing out. *

0 Not True or Hardly Ever True

1 Somewhat True or Sometimes True

2 Very True or Often True

8. I follow my mother or father wherever they go. *

0 Not True or Hardly Ever True

1 Somewhat True or Sometimes True

2 Very True or Often True

9. People tell me that I look nervous. *

0 Not True or Hardly Ever True

1 Somewhat True or Sometimes True

2 Very True or Often True

10. I feel nervous with people I don’t know well. *

0 Not True or Hardly Ever True

1 Somewhat True or Sometimes True

2 Very True or Often True

11. I get stomachaches at school. *

0 Not True or Hardly Ever True

1 Somewhat True or Sometimes True

2 Very True or Often True

12. When I get frightened, I feel like I am going crazy. *

0 Not True or Hardly Ever True

1 Somewhat True or Sometimes True

2 Very True or Often True

13. I worry about sleeping alone. *

0 Not True or Hardly Ever True

1 Somewhat True or Sometimes True

2 Very True or Often True

14. I worry about being as good as other kids. *

0 Not True or Hardly Ever True

1 Somewhat True or Sometimes True

2 Very True or Often True

15. When I get frightened, I feel like things are not real. *

0 Not True or Hardly Ever True

1 Somewhat True or Sometimes True

2 Very True or Often True

16. I have nightmares about something bad happening to my parents. *

0 Not True or Hardly Ever True

1 Somewhat True or Sometimes True

2 Very True or Often True

17. I worry about going to school. *

0 Not True or Hardly Ever True

1 Somewhat True or Sometimes True

2 Very True or Often True

18. When I get frightened, my heart beats fast. *

0 Not True or Hardly Ever True

1 Somewhat True or Sometimes True

2 Very True or Often True

20. I have nightmares about something bad happening to me. *

0 Not True or Hardly Ever True

1 Somewhat True or Sometimes True

2 Very True or Often True

21. I worry about things working out for me. *

0 Not True or Hardly Ever True

1 Somewhat True or Sometimes True

2 Very True or Often True

22. When I get frightened, I sweat a lot. *

0 Not True or Hardly Ever True

1 Somewhat True or Sometimes True

2 Very True or Often True

24. I get really frightened for no reason at all. *

0 Not True or Hardly Ever True

1 Somewhat True or Sometimes True

2 Very True or Often True

25. I am afraid to be alone in the house. *

0 Not True or Hardly Ever True

1 Somewhat True or Sometimes True

2 Very True or Often True

26. It is hard for me to talk with people I don’t know well. *

0 Not True or Hardly Ever True

1 Somewhat True or Sometimes True

2 Very True or Often True

27. When I get frightened, I feel like I am choking. *

0 Not True or Hardly Ever True

1 Somewhat True or Sometimes True

2 Very True or Often True

28. People tell me that I worry too much. *

0 Not True or Hardly Ever True

1 Somewhat True or Sometimes True

2 Very True or Often True

29. I don’t like to be away from my family. *

0 Not True or Hardly Ever True

1 Somewhat True or Sometimes True

2 Very True or Often True

30. I am afraid of having anxiety (or panic) attacks. *

0 Not True or Hardly Ever True

1 Somewhat True or Sometimes True

2 Very True or Often True

31. I worry that something bad might happen to my parents. *

0 Not True or Hardly Ever True

1 Somewhat True or Sometimes True

2 Very True or Often True

32. I feel shy with people I don’t know well. *

0 Not True or Hardly Ever True

1 Somewhat True or Sometimes True

2 Very True or Often True

33. I worry about what is going to happen in the future. *

0 Not True or Hardly Ever True

1 Somewhat True or Sometimes True

2 Very True or Often True

34. When I get frightened, I feel like throwing up. *

0 Not True or Hardly Ever True

1 Somewhat True or Sometimes True

2 Very True or Often True

35. I worry about how well I do things. *

0 Not True or Hardly Ever True

1 Somewhat True or Sometimes True

2 Very True or Often True

36. I am scared to go to school. *

0 Not True or Hardly Ever True

1 Somewhat True or Sometimes True

2 Very True or Often True

37. I worry about things that have already happened. *

0 Not True or Hardly Ever True

1 Somewhat True or Sometimes True

2 Very True or Often True

38. When I get frightened, I feel dizzy. *

0 Not True or Hardly Ever True

1 Somewhat True or Sometimes True

2 Very True or Often True

39. 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.) *

0 Not True or Hardly Ever True

1 Somewhat True or Sometimes True

2 Very True or Often True

40. I feel nervous when I am going to parties, dances, or any place where there will be people that I don’t know well. *

0 Not True or Hardly Ever True

1 Somewhat True or Sometimes True

2 Very True or Often True

SCORING: A total score of ≥ 25 may indicate the presence of an Anxiety Disorder. Scores higher that 30 are more specific. 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. A score of 9 for items 5, 7, 14, 21, 23, 28, 33, 35, 37 may indicate Generalized Anxiety Disorder. A score of 5 for items 4, 8, 13, 16, 20, 25, 29, 31 may indicate Separation Anxiety Disorder. A score of 8 for items 3, 10, 26, 32, 39, 40, 41 may indicate Social Anxiety Disorder. A score of 3 for items 2, 11, 17, 36 may indicate Significant School Avoidance.

*For children ages 8 to 11, it is recommended that the clinician explain all questions, or have the child answer the questionnaire sitting with an adult in case they have any questions.

Developed by Boris Birmaher, M.D., Suneeta Khetarpal, M.D., Marlane Cully, M.Ed., David Brent M.D., and Sandra McKenzie, Ph.D., Western Psychiatric Institute and Clinic, University of Pgh. (10/95). E-mail: birmaherb@msx.upmc.edu