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Q.1
When you are all at home for the day, does your child follow you around the house wherever you go? *

Q.2
Does your child often come home sick from school with a stomachache or headache? *

Q.3
Is your child easily fatigued and/or complain of sore muscles? *

Q.4
Has your child ever gotten so scared that she says it’s hard to breathe? *

Q.5
At birthday parties, does your child feel nervous if left with people she doesn’t know very well? *

Q.6
Are you woken frequently in the night because your child had another nightmare about something bad happening to you? *

Q.7
Does your child change clothes several times a day because she sweats a lot when she is nervous? *

Q.8
Is your child scared to get on the bus and go to school every day? *

Q.9
Does your child expect the worst, even when there is no justification for worry? *

Q.10
Even when you are upstairs and your child is in the basement, does he get scared about being alone in the house? *

Q.11
Does your child fill her bed with stuffed animals and the family pet because she is too nervous to sleep alone? *

Q.12
Has your child come home from a slumber party because she’s too scared to sleep away from home? *

Q.13
Have teachers mentioned that your child seems nervous working in groups or speaking in class? *

Q.14
After school, does your child spend an excessive amount of time doing and redoing homework worksheets because he doesn’t want anything to be less than perfect? *

Q.15
Is your child irrationally afraid of flying in an airplane, or of a certain animal? *

Q.16
Does your child tremble when she’s in crowded places like the shopping mall or a busy playground? *

Q.17
Does your child require constant approval and reassurance that she’s done a good job? *

Q.18
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