Instructions: The following questions ask about thoughts, feelings, and behaviors that you may have had about being separated from home or from people who are important to you. Please rate how often the following statements are true for you.
felt moments of sudden terror, fear, or fright when separated
felt anxious, worried, or nervous about being separated
have had thoughts of bad things happening to people important to me or bad things happening to me when separated from them (e.g., getting lost, accidents)
felt a racing heart, sweaty, trouble breathing, faint, or shaky when separated
felt tense muscles, felt on edge or restless, or had trouble relaxing or trouble sleeping when separated
avoided going places where I would be separated
when separated, left places early to go home
spent a lot of time preparing for how to deal with separation
distracted myself to avoid thinking about being separated
needed help to cope with separation (e.g., alcohol or medications, superstitious objects)