Severity Measure for Specific Phobia

Severity Measure for Specific Phobia - Adult
Name*

First NameMiddle NameLast Name
Medical Record #*
Date

MonthDayYear
Date
The following questions ask about thoughts, feelings, and behaviors that you may have had in a variety of situations. Please check (✓) the item below that makes you most anxious.
Choose only one item and make your ratings based on the situations included in that item:

Driving, flying, tunnels, or bridges, or enclosed spacesAnimals or insectsHeights, storms, or waterBlood, needles, or injectionsChoking or vomiting

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 these situations
felt anxious, worried, or nervous about these situations
had thoughts of being injured, overcome with fear, or other bad things happening in these situations
felt a racing heart, sweaty, trouble breathing, faint, or shaky in these situations
felt tense muscles, felt on edge or restless, or had trouble relaxing in these situations
avoided, or did not approach or enter, these situations
moved away from these situations or left them early
spent a lot of time preparing for, or procrastinating about (i.e., putting off), these situations
distracted myself to avoid thinking about these situations
needed help to cope with these situations (e.g., alcohol or medications, superstitious objects, other people)

Severity Measure for Specific Phobia - Adult