Screen for Child Anxiety Related Disorders (SCARED) Child Version (To be filled out by the Child)
Patient name
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First Name
Last Name
Who should form be sent to/who is your appointment with?
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Agganis, Georgia
Aldrich, Meghan
Amin, Priyal
Athanasiou, Andreas
Balestrieri, Karen
Coleman, Russell
Daly, James
Eagan, Joan
Foley, Megan
Goharfar, Behzad
Grossman, Emily
Hall, Alexandra
Hiltunen, Karen
Hohmann, Deanna
Jackson, Patricia
Jensen, Susan
Jones, Eliza
Kelleher, Susan
Laurin Kinney, Jayne
Leonhardt, Julie Bonner
Narayan, Sara
Oliver, Dana
Scott, Kendra
Sheehy, James
Stimpson, Devin
Suriani, Christine
Triehy-Kreitler, Ashley
Voute, Susan
Wilson, Kathryn
*** Other ***
Patient date of birth
*
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Month
-
Day
Year
Date
Chose the number that best describe the child's behavior over the past 6 months
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
1. When I feel frightened, it is hard for me to breathe
2. I get headaches when I am at school
3. I don’t like to be with people I don’t know well
4. I get scared if I sleep away from home
5. I worry about other people liking me
6. When I get frightened, I feel like passing out
7. I am nervous
8. I follow my mother or father wherever they go
9. People tell me that I look nervous
10. I feel nervous with people I don’t know well
11. I get stomachaches at school
12. When I get frightened, I feel like I am going crazy
13. I worry about sleeping alone
14. I worry about being as good as other kids
15. When I get frightened, I feel like things are not real
16. I have nightmares about something bad happening to my parents
17. I worry about going to school
18. When I get frightened, my heart beats fast
19. I get shaky
20. I have nightmares about something bad happening to me
21. I worry about things working out for me
22. When I get frightened, I sweat a lot
23. I am a worrier
24. I get really frightened for no reason at all
25. I am afraid to be alone in the house
26. It is hard for me to talk with people I don’t know well
27. When I get frightened, I feel like I am choking
28. People tell me that I worry too much
29. I don’t like to be away from my family
30. I am afraid of having anxiety (or panic) attacks
31. I worry that something bad might happen to my parents
32. I feel shy with people I don’t know well
33. I worry about what is going to happen in the future
34. When I get frightened, I feel like throwing up
35. I worry about how well I do things
36. I am scared to go to school
37. I worry about things that have already happened
38. When I get frightened, I feel dizzy
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)
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
41. I am shy
Anxiety Disorder (>=25)
Panic Disorder or Significant Somatic Symptoms (>=7)
Generalized Anxiety Disorder (>=9)
Separation Anxiety Disorder (>=5)
Social Anxiety Disorder (>=8)
School Avoidance (>=3)
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