Severity Measure for Social Anxiety Disorder (Social Phobia)

Severity Measure for Social Anxiety Disorder (Social Phobia) - Adult
Name*

First NameMiddle NameLast Name
Medical Record #*
Date

MonthDayYear
Date
Instructions: The following questions ask about thoughts, feelings, and behaviors that you may have had about social situations. Usual social situations include: public speaking, speaking in meetings, attending social events or parties, introducing yourself to others, having conversations, giving and receiving compliments, making requests of others, and eating and writing in public.

During the PAST 7 DAYS, I have...

Rows	Never	Occasionally	Half of the time	Most of the time	All of the time
felt moments of sudden terror, fear, or fright in social situations
felt anxious, worried, or nervous about social situations
had thoughts of being rejected, humiliated, embarrassed, ridiculed, or offending others
felt a racing heart, sweaty, trouble breathing, faint, or shaky in social situations
felt tense muscles, felt on edge or restless, or had trouble relaxing in social situations
avoided, or did not approach or enter, social situations
left social situations early or participated only minimally (e.g., said little, avoided eye contact)
spent a lot of time preparing what to say or how to act in social situations
distracted myself to avoid thinking about social situations
needed help to cope with social situations (e.g., alcohol or medications, superstitious objects)

Severity Measure for Social Anxiety Disorder (Social Phobia) - Adult