Social Phobia Assessment
Please fill the Form below. Answer all the Questions. Dont think too much. Fill it With The Answer that comes first to your mind. Your response will be kept confidential. It will be used only for treatment and research purpose. Copyright © 2021 psyclinic
Name/Nick name
Email
example@example.com
Date of filling the form
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Month
-
Day
Year
Date
Give a short description of your problem
Do you use any substance like alcohol, cannabis, opiates, nicotine etc. If yes please specify the type of substance, quantity of intake, how often use it etc.
Please tick the appropriate column.
Never
Rarely
Some times
Most times
Always
I keep away from people and so avoid parties, gatherings etc.
I feel uneasy when I am around people
I avoid giving speeches
I avoid talking to strangers
I prefer to follow written instructions and sign boards than seeking help from others
I feel uneasy to to approach people in authority
I feel very uneasy at parties and gatherings
I feel very uneasy when I become the centre of attention
I cant withstand criticism
My heart rate becomes faster when I am around people
Submit
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