Social Anxiety Screening Tool

This is a screening measure to help you determine whether you might have social anxiety that needs professional attention. This screening tool is not designed to make a diagnosis of social anxiety but to be shared with Summit Behavioral Health mental health professional to inform further conversations about diagnosis and treatment.

INSTRUCTIONS

1) Fill and submit shown form

2) Choose if you want to be contacted by Summit BHP staff

3) Select date/time for brief virtual meeting

Date *

Date

Are you troubled by the following?

	Response
An intense and persistent fear of a social situation in which people might judge you such as:
Social interactions (e.g., having a conversation, meeting unfamiliar people)
Being observed (e.g., eating or drinking in public)
Performing in front of others (e.g., giving a speech)
Fear that you will act in a way or show anxiety symptoms that will be negatively evaluated (i.e., will be humiliating or embarrassing; will lead to rejection or offend others)
Fear that people will notice that you are blushing, sweating, trembling, or showing other signs of anxiety
Perceiving that your reaction to feared situations to be greater than most other people

Does a feared situation cause you to

	Response
always feel anxious?
experience a panic attack, during which you suddenly are overcome by intense fear or discomfort, including any of these symptoms:
Pounding heart
Sweating
Trembling or shaking
Choking
Chest pain
Trembling or shaking
Nausea or abdominal discomfort
"Jelly" legs
Dizziness
Feelings of unreality or being detached from yourself
Fear of losing control or “going crazy”
Fear of dying
Numbness or tingling sensations
Chills or hot flushes
go to great lengths to avoid participating?
have your symptoms interfere with your daily life?

Having more than oneillness at the same time can make it difficult to diagnose and treat thedifferent conditions. Depression and substance abuse are among the conditionsthat occasionally complicate social anxiety disorder.

	Response
Have you experienced changes in sleeping or eating habits?

More days than not, do you feel…

	Response
Sad or depressed?
Disinterested in life?
Worthless or guilty?

During the last year, has the use of alcohol or drugs...

	Response
resulted in your failure to fulfill responsibilities with work, school, or family?
placed you in a dangerous situation, such as driving a car under the influence?
gotten you arrested?
continued despite causing problems for you or your loved ones?

During the past six months, have you often been bothered by any of the following symptoms? Check the score to each symptom that you have had more days than not:

1. restlessness or feeling keyed up or on edge

2. irritability

3. difficulty falling/staying asleep or restless/unsatisfying sleep

4. being easily fatigued

5. difficulty concentrating or mind going blank

6. muscle tension

How much do worry and physical symptoms interfere with your life, work, social activities, family, etc.?

Howmuch are you bothered by worry and physical symptoms (how much distress does itcause you)?

Do you consent to Summit BHP contacting you to discuss your results and care options? *

Appointment

If you answered Yes to the question above, please fill following section. We offer new patient appointments onsite and online within 1-3 days of submitting a request.

Name

First Name Last Name

Age

Gender

Phone Number

Area Code Phone Number

Summit Behavioral Health

2115 County Road D East, Suite C-100, Maplewood, MN 55109

Ph: 651-358-7020 www.SummitBHP.com