SCARED-Parent version Questionnaire - Woodinville Pediatrics

Parent: please fill out for your child before your telehealth appointment. Respond with the best answer that seems to describe your child for the last 3 months.

Your name and relationship to patient *

Telehealth Appointment Provider *

Patient Name *

First

Last

Date of Birth *

Email *

1. When my child feels frightened, it is hard for him/her to breathe *

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

2. My child gets headaches when he/she is at school *

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

3. My child doesn’t like to be with people he/she doesn’t know well *

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

4. My child gets scared if he/she sleeps away from home *

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

5. My child worries about other people liking him/her *

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

6. When my child gets frightened, he/she feels like passing out *

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

7. My child is nervous *

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

8. My child follows me wherever I go *

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

9. People tell me that my child looks nervous *

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

10. My child feels nervous with people he/she doesn’t know well *

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

11. My child gets stomachaches at school *

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

12. When my child gets frightened, he/she feels like he/she is going crazy *

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

13. My child worries about sleeping alone *

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

14. My child worries 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 he/she gets frightened, he/she feels like things are not real *

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

16. My child has nightmares about something bad happening to his/her parents *

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

17. My child worries about going to school *

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

18. When my child gets scared, his/her heart beats fast *

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

19. He/she gets shaky *

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

20. My child has nightmares about something bad happening to him/her *

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

21. My child worries about things working out for him/her *

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

22. When my child gets frightened, he/she sweats a lot *

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

23. My child is a worrier *

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

24. My child gets really frightened for no reason at all *

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

25. My child is 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 my child to talk with people he/she doesn’t know well *

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

27. When my child gets frightened, he/she feels like he/she is choking *

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

28. People tell me that my child worries too much *

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

29. My child doesn’t like to be away from his/her family *

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

30. My child is afraid of having anxiety (or panic) attacks *

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

31. My child worries that something bad might happen to his/her parents *

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

32. My child feels shy with people he/she doesn’t know well *

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

33. My child worries 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 my child gets frightened, he/she feels like throwing up *

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

35. My child worries about how well he/she does things *

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

36. My child is scared to go to school *

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

37. My child worries about things that have already happened *

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

38. When my child gets frightened, he/she feels dizzy *

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

39. My child feels nervous when he/she is with other children or adults and he/she has to do something while they watch him/her (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. My child feels nervous when he/she is going to parties, dances, or any place where there will be people that he/she doesn’t know well *

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

41. My child is shy *

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

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