Child Anxiety Questionnaire

To inquire about our services, contact

Dr. Bruce Miller
(610) 642-4873 x24

Center Programs > Anxiety Disorders Program >
Child anxiety questionnaire for parents

IS YOUR CHILD ANXIOUS? A QUESTIONNAIRE FOR PARENTS.

If you are unsure whether or not your child's difficulties involve anxiety, print and complete this questionnaire.

You can then show it to the Director of the Child Anxiety Program when you arrive for your initial evaluation.

_ 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_ Yes _ No		Is your child shy, timid, or withdrawn?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?

CENTER FOR PSYCHOLOGICAL SERVICES
Locations in Ardmore and Paoli, Pennsylvania.