UPDOX - PATIENT PORTAL

Today's Date * Child's Name * Child's DOB * name of parent/guardian fillng out form *

Below is a list of statements that describe how people feel. Reed each statement carefully and decide if it is "not true / hardly ever true" or "Somewhat true / Sometimes true" or "Very true / often true" for your child. Than for each statement, fill in one circle that corresponds to the response that seems to describe your child for the last 3 months. Please respond to all statements as well as you can, even if some do not seem to concern your child.

0= NOT TRUE OR HARDLY EVER TRUE 1= SOMEWHAT TRUE OR SOMETIMES TRUE 2=VERY TRUE OR OFTEN TRUE

1. When my child feels frightened, it is hard for him/her to breath 2. My child gets headaches while at school 3. My child does not like to be with people he / she doesd not know well 4. My child gets scared if he/she sleeps away from home. 5. My child worries about other people liking him/her 6. When my child gets frightened, he/she feels like passing out. 7. My child is nervous 8. My child follows me everywhere I go. 9. People tell me that my child looks nervious 10. My child feels nervous with people he/she doesn't know well. 11. My child gets stomachaches at school 12. When my child gets frightened, he/she feels like he/she is going crazy 13. My child worries about sleeping alone 14. My child worries about being as good as other kids 15. When he/she gets frightened, he/she feels like things are not real 16. My child has nightmares about something happening to his her parenst 17. My child worries about going to school 18. When my child gets scared his/her heart beats fast 19. He/she gets shaky 20. My child has nightmares about something bad happening to him/her. 21. My child worries about things working out for him/her 22. When my child gets frightened, he/she sweats a lot 23. My child is a worrier 24. My child get very frightened for no reason at all 25. My child is afraid to be alone at home 26. It is hard for my child to talk with people he/she doesn't know well 27. When my child gets frightened, he/she feels like he/she is choking 28. People tell me that my child worries to much 29. My child doesn't like to be away from his/her family 30. My child is afraid of having anxiety (or panic) attacks 31. My child worries that something bad might happen to his/her parents 32. My child feels shy with people he/she doesn't know very well 33. My child worries about what is going to happen in the future 34. When my child feels frightened, he/she feels like throwing up 35. My child worries about how well he/she does things. 36. My child is scared to go to school 37. My child worries about things that have already happened 38. When my child get frightened, he/she feels dizzy 39. My child feels nervious when he/she is with other children or adults & he/she has to do something while they watch him/her (for example: read aloud, speak, play a game, play a sport) 40. My child feels nervious when he/she goes to parties, dances, or any place where there will be people that he/she doesn't know well 41. My child is shy Electronic signature of parent/guardian *