Belowisalistofitemsthatdescribechildren.Foreachitempleasecircletheresponsethatbestdescribes
thechild.Pleasecirclethe4iftheitemisveryoftentrue,3iftheitemisquiteoftentrue,2iftheitem
issometimestrue,1iftheitemisseldomtrueorifitisnottrueatallcirclethe0.Pleaseanswerallthe
itemsaswellasyoucan,evenifsomedonotseemtoapplytothischild.
0=NotAtAllTrue1=SeldomTrue2=SometimesTrue3=QuiteOftenTrue4=VeryOftenTrue
1.Repeatedlyasksaboutparent(s)duringtheday...............................................
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2.Hasdifficultystoppinghim/herselffromworrying..........................................
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3.Keepscheckingthathe/shehasdonethingsright(e.g.,thathe/sheclosedadoor,
turnedoffatap).........................................................................................
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4.Complainsofheadachesorstomachacheswhenitistimetobedroppedoffat
preschool/school.................................................................................................
01234
5.Istense,restlessorirritableduetoworrying....................................................
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6.Isscaredtoaskanadultforhelp(e.g.,apreschoolorschoolteacher).............
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7.Isscaredofheights(highplaces)....................................................................
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8.Washeshis/herhandsoverandovermanytimeseachday................................
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9.Isafraidofmeetingortalkingtounfamiliarpeople........................................
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10.Worriesthatsomethingbadwillhappentohis/herparents.............................
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11.Spendsalargepartofeachdayworryingaboutvariousthings.....................
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12.Isafraidoftalkinginfrontoftheclass(preschoolgroup)e.g.,showandtell
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13.Worriesthatsomethingbadmighthappentohim/her(e.g.,gettinglostor
kidnapped),sohe/shewontbeabletoseehis/herparentsagain..........................
01234
14.Hastohavethingsinexactlytherightorderorpositiontostopbadthingsfrom
happening..................................................................................................
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15.Worriesthathe/shewilldosomethingembarrassinginfrontofotherpeople
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16.Isafraidofinsectsand/orspiders...................................................................
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17.Hasbadorsillythoughtsorimagesthatkeepcomingbackoverandover.....
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18.Becomesdistressedwhenhe/sheisdroppedoffatpreschool/school...............
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19.Isafraidtogouptoagroupofchildrenandjointheiractivities....................
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20.Hastokeepthinkingspecialthoughts(e.g.,numbersorwords)tostopbad
thingsfromhappening........................................................................................
01234
21.Asksforreassurancewhenitdoesntseemnecessary....................................
01234
22.Criesforparentwhilstatpreschool/school.....................................................
01234
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