Screen for Child Anxiety Disorder (SCARED) Parent Version
Patient name
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First Name
Last Name
Patient date of birth
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Month
-
Day
Year
Date
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 ***
Below is a list of sentences of how people feel. Read each phrase and decide if it is "Not true or hardly ever true", "Somewhat true or sometimes true",Very true or often true" for you.
Not true or hardly ever true
Somewhat true or sometimes true
Very true or often true
1. When my child feels frightened, it is hard for him/her to breathe
2. My child gets headaches when he/she is at school
3. My child doesn’t like to be with people he/she doesn’t know well
4. My child gets scared if he/she sleeps away from home
5. My child worries about other people liking him/her
6. When my child gets frightened, he/she feels like passing out
7. My child is nervous
8. My child follows me wherever I go
9. People tell me that my child looks nervous
10. My child feels nervous with people he/she doesn’t know well
11. My child gets stomachaches at school
12. When my child gets frightened, he/she feels like he/she is going crazy
13. My child worries about sleeping alone
14. My child worries about being as good as other kids
15. When he/she gets frightened, he/she feels like things are not real
16. My child has nightmares about something bad happening to his/her
parents
17. My child worries about going to school
18. When my child gets frightened, his/her heart beats fast
19. He/she gets shaky
20. My child has nightmares about something bad happening to him/her
21. My child worries about things working out for him/her
22. When my child gets frightened, he/she sweats a lot
23. My child is a worrier
24. My child gets really frightened for no reason at all
25. My child is afraid to be alone in the house
26. It is hard for my child to talk with people he/she doesn’t know well
27. When my child gets frightened, he/she feels like he/she is choking
28. People tell me that my child worries too much
29. My child doesn’t like to be away from his/her family
30. My child is afraid of having anxiety (or panic) attacks
31. My child worries that something bad might happen to his/her parents
32. My child feels shy with people he/she doesn’t know well
33. My child worries about what is going to happen in the future
34. When my child gets frightened, he/she feels like throwing up
35. My child worries about how well he/she does things
36. My child is scared to go to school
37. My child worries about things that have already happened
38. When my child gets frightened, he/she feels dizzy
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)
40. My child feels nervous when he/she is going to parties, dances, or any place where there will be people that he/she don't know well
41. My child is 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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