| _ Yes _ No |
|
Does your child have an excessive fear of separation from parents
or from home? |
|
|
|
| _ Yes _ No |
|
Does your child refuse to go to or stay in school? |
|
|
|
| _ Yes _ No |
|
Does your child make either multiple calls home or several trips to the school nurse during the school day? |
|
|
|
| _ Yes _ No |
|
When your child is away from you, does he/she child worry that some danger or harm will come to him/her, you, or other loved ones (e.g., car accident, getting lost, being kidnapped)? |
|
|
|
| _ Yes _ No |
|
Does your child worry excessively about a number of things (e.g., performance in school and sports, health, friends, family, punctuality)? |
|
|
|
| _ Yes _ No |
|
Is your child unable to shop himself/herself from worrying? |
|
|
|
| _ Yes _ No |
|
Is your child overly perfectionistic? |
|
|
|
| _ Yes _ No |
|
Is your child excessively irritable? |
|
|
|
| _ Yes _ No |
|
Does your child have difficulty sleeping or eating? |
|
|
|
| _ Yes _ No |
|
Does your child have difficulty sitting still or appear fidgety and restless? |
|
|
|
| _ Yes _ No |
|
Does your child complain of headaches, nausea, stomachaches, and/or muscle aches? |
|
|
|
| _ Yes _ No |
|
Is your child shy, timid, or withdrawn? |
|
|
|
| _ Yes _ No |
|
Does your child fear being embarrassed in social situations? |
|
|
|
| _ Yes _ No |
|
Does your child refuse to speak in situations where speaking is expected? |
|
|
|
| _ Yes _ No |
|
Does your child have an unreasonable fear of a specific object or situation (e.g., animals, planes, dark, needles, thunder, oral reports)? |
|
|
|
| _ Yes _ No |
|
Does your child often think the same thought over and over, even though the thoughts might seem senseless or silly? |
|
|
|
| _ Yes _ No |
|
Does your child repeat behaviors such as washing, checking, or counting in order to prevent something bad from happening? |
|
|
|
| _ Yes _ No |
|
Has your child experienced a significant stressor to which he/she seems to be having a difficult time adjusting? |
|
|
|
| _ Yes _ No |
|
Does your child ever have periods during which he/she gets extremely nervous or panicky for no apparent reason?
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