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 your child. Then. 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.
1. When my child feels frightened, it is hard for them to breathe
2. My child gets headaches when them is at school.
3. My child doesn't like to be with people them doesn't know well.
4. My child gets scared if they sleep away from home.
5. My child worries about other people liking them.
6. When my child gets frightened, they feel like passing out.
8. My child follows me wherever I go.
9. People tell me that my child looks nervous.
10. My child feels nervous with people they don't know well.
11. My child gets stomachaches at school.
12. When my child gets frightened, they feel like they are going crazy.
13. My child worries about sleeping alone.
14. My child worries about being as good as other kids.
15. When my child gets frightened, they feel like things are not real.
16. My child has nightmares about something bad happening to their parents.
17. My child worries about going to school.
18. When my child gets frightened, their heart beats fast.
20. My child has nightmares about something bad happening to them.