Measures included:
24 You do the best in vour class on a paper.
I am good at putting puzzles together... Q I am good at doing manv things... Q I am not good at sports...O The others who tried out were verv good at sports... Q All tests are hard...O Onlv some tests are hard...CH I got the shot iust right... [ ] The goalkeeper was easv to beat... O The others in mv class did not work hard on their papers O I worked hard on the paper...Q
Please put a cross in the box under the word that describes how often you
react this way. Remember to put a cross in only one box. ^
/ / /
1 I don't w ant other p eo p le to know w hen I'm afraid... Q Q Q 2 W hen I can n ot k eep mv mind on mv schoolw ork, I worry that I might b e going cra zv ... O Q [%] 3 It s c a r e s m e w h en I feel "shakv"... Q Q Q 4 It s c a r e s m e w h en I feel like I am going to faint... Q Q Q 5 It is important for m e to sta v in control of mv fe e lin g s... Q Q Q 6 It s c a r e s m e w h en m v heart b e a ts fa s t... Q [ ] Q 7 It e m b a r r a s se s m e w h en mv stom ach grow ls (m a k es n o is e )... Q Q Q 8 It s c a r e s m e w h en I feel like I am going to throw up... Q Q Q 9 W hen I n otice that mv heart is beating fast, I worry that there might b e som eth in g w rong with m e . . I I I I I I 10 It s c a r e s m e w h en I h a v e trouble getting breath... Q [ ] [%] 11 W hen mv sto m a ch hurts, I worry that I might b e reallv sick ... [ ] Q 0 12 It s c a r e s m e w h en I cannot k eep mv mind on sch oolw ork ... I I I I I I 13 O thers mv a g e ca n tell w hen I fe e l sh a k v ... I I I I I I 14 U nusual fe e lin g s in mv bodv sc a r e m e ... I I I I I I 15 W hen I am afraid, I worry that I might be crazv...EH EH EH
16 It s c a r e s m e w h en I fe e l n erv o u s...EH EH EH
17 I don't like to let mv feelin g s sh o w ...EH EH EH
Please put a cross in the box under the word that shows how often
each of these things happen to you. Rem em ber to put a cross in only
I
one box./ /
/
1 1 worry about th in g s...
□ □ □ □
2 1 am scared of the d a rk ...
■n □ □ □
3 When 1 have a problem, 1 get a funny feeling In my stom ach...■n □ □ □
4 1 feel a fra id ...n □ □ □
5 1 would feel afraid of being on my own at h o m e ...n □ □ □
6 1 feel scared when 1 have to take a te s t...n □ □ □
7 1 feel afraid if 1 have to use public to ilets...■n □ □ □
8 1 worry about being away from my p arents...•n □ □ □
9 1 feel afraid that 1 will make a fool of myself in front of p eop le...□ □ □ □
10 1 worry that 1 will do badly at my schoolwork...
■n □ □ □
11 1 am popular amongst others my own a g e ...n □ □ □
12 1 worry that something awful will happen to someone in my family...•n □ □ □
13 1 suddenly feel as if 1 can't breathe when there is no reason for this...■n □ □ □
14 1 have to keep checking that 1 have done things right, (e.g. the switch is off, the door is locked)□ □ □ □
15 1 feel scared if 1 have to sleep on my o w n ...■n □ □ □
16 1 have trouble going to school in the mornings because 1 feel nervous or a fra id ...n □ □ □
17 1 am good at sports...■n □ □ □
18 1 am scared of d o g s ...n □ □ □
19 1 can't seem to get bad or silly thoughts out of my h e a d ...■n □ □ □
20 When 1 have a problem, my heart beats really fa s t...□ □ □ □
21 1 suddenly start to tremble or shake when there is no reason for th is ...
□ □ □ □
22 1 worry that something bad will happen to m e ...
□ □ □ □
23 1 am scared of going to the doctor or dentist...
□ □ □ □
24 When 1 have a problem, 1 feel sh a k y ...
□ □ □ □
25 1 am scared of being in high places or lifts...n □ □ □
26 1 am a good p erson...n □ □ □
27 1 have to think of special thoughts to stop bad things from happening (like numbers or w o rd s).□ □ □ □
28 1 feel scared if 1 have to travel in the car, on a bus or tra in ...n □ □ □
29 1 worry what other people think of m e ...■n □ □ □
31 I feel happy... 0 0 0 0