SCARED-Child version Questionnaire - Woodinville Pediatrics

Please fill out before your telehealth appointment. Respond with the best answer that seems to describe you for the last 3 months.

Name *

First

Last

Telehealth Appointment Provider *

Date of Birth *

Email *

1. When I feel frightened, it is hard for me to breath *

Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true

2. I get headaches when I am at school *

Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true

3. I don’t like to be with people I don’t know well *

Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true

4. I get scared if I sleep away from home *

Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true

5. I worry about other people liking me *

Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true

6. When I get frightened, I feel like passing out *

Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true

7. I am nervous *

Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true

8. I follow my mother or father wherever they go *

Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true

9. People tell me that I look nervous *

Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true

10. I feel nervous with people I don’t know well *

Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true

11. I get stomachaches at school *

Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true

12. When I get frightened, I feel like I am going crazy *

Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true

13. I worry about sleeping alone *

Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true

14. I worry about being as good as other kids *

Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true

15. When I get frightened, I feel like things are not real *

Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true

16. I have nightmares about something bad happening to my parents *

Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true

17. I worry about going to school *

Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true

18. When I get frightened, my heart beats fast *

Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true

19. I get shaky *

Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true

20. I have nightmares about something bad happening to me *

Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true

21. I worry about things working out for me *

Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true

22. When I get frightened, I sweat a lot *

Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true

23. I am a worrier *

Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true

24. I get really frightened for no reason at all *

Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true

25. I am afraid to be alone in the house *

Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true

26. It is hard for me to talk with people I don’t know well *

Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true

27. When I get frightened, I feel like I am choking *

Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true

28. People tell me that I worry too much *

Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true

29. I don’t like to be away from my family *

Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true

30. I am afraid of having anxiety (or panic) attacks *

Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true

31. I worry that something bad might happen to my parents *

Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true

32. I feel shy with people I don’t know well *

Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true

33. I worry about what is going to happen in the future *

Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true

34. When I get frightened, I feel like throwing up *

Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true

35. I worry about how well I do things *

Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true

36. I am scared to go to school *

Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true

37. I worry about things that have already happened *

Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true

38. When I get frightened, I feel dizzy *

Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true

39. I feel nervous when I am with other children or adults and I have to do something while they watch me (for example: read aloud, speak, play a game, play a sport) *

Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true

40. I feel nervous when I am going to parties, dances, or any place where there will be people that I don’t know well *

Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true

41. I am shy *

Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true

Comment or Message

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