Does my child have an anxiety disorder?

1. Age of child

1
2
3
4-5
6-7
8-10
10-12
Over 12
Please make a selection.

2. In which of the following situations is your child anxious? (please tick all that apply)

Upon separation from mum
Upon separation from dad
In new environments
Meeting new people
Anxious at being left at school/nursery
Anxious if left with well known friends and relatives
Anxious while with parents in a familiar situation
Anxious in one or two isolated situations only

Please describe

3. How long has anxiety been an issue for this child?

1 month
2-4 months
4-6 months
6 months to 1 year
Longer than a year
Please make a selection.

4. Have there been any significant family changes, bereavements, traumas in the child's lifetime?

No
Yes - Please make a selection.Please describe

5. Are there any other children in the family with similar fears/phobias?

No
Yes
Please make a selection.

6. Did either parent have childhood phobias, persistent nightmares or anxiety problems?

Mother

No
Yes
Please make a selection.

Father

No
Yes
Please make a selection.

7. Is the anxiety consistent or does it come and go depending on how settled the child is feeling at any stage?

Consistent
Intermittent
Please make a selection.

8. Is the child equally anxious with any carer?

Yes
No - more anxious with Mum
No - more anxious with Dad
No - more anxious with another carer
Please make a selection.

9. How severe is the anxiety at its very worst?

Crying, screaming, inconsolable
Very nervous, crying, clingy
Anxious, quiet/clingy
Anxious but able to be comforted by adult reassurance
Please make a selection.

10. How severe is the anxiety most usually?

Crying, screaming, inconsolable
Very nervous, crying, clingy
Anxious, quiet/clingy
Anxious but able to be comforted by adult reassurance
Please make a selection.

11. Does your child have any of the following symptoms? (please tick all that apply)

Continual shaking
Occasional shaking
Nail biting to the point of causing bleeding
Mild nail biting
Persistent nightmares (more than once a month)
Persistent bedwetting past the age of 6
Any ticks or twitches
Freezing in the middle of an activity
Hyperactivity
Persistent clothes wetting our soiling past the age of 4

12. Does your child have any recurrent physical symptoms which do not have a known medical cause? Such as (please tick all that apply)

Stomach pains
Nausea
Faintness
Headaches

13. If the child is of an age to speak clearly: How able is your child to discuss their anxiety?

Able to talk about what they are anxious about but not able to stop being anxious
Not able to say what it is they are anxious about, but can talk about it
Gets too scared thinking about it to be able to talk
Please make a selection.

14. Does your child have specific persistent worries? Such as (please tick all that apply)

Worries about the parents coming to harm
About traffic or other accidents
About illnesses in the family
About being lost or kidnapped
Other - Please describe

15. Does your child refuse to go to school or another environment which requires separation from parents?

Yes
No
Please make a selection.

16. Is your child reluctant to sleep away from the home without parents?

Yes
No
Please make a selection.

17. Is your child reluctant to sleep away from home even with the parents, for example on holiday?

Yes
No
Please make a selection.

18. On a scale of 1-10 how disruptive are your child's anxieties to the child's daily life?

1 2 3 4 5 6 7 8 9 10 Select

19. On a scare of 1-10 how disruptive are these anxieties to the parent's daily life?

1 2 3 4 5 6 7 8 9 10 Select

20. Does your child's difficulty have a significant on any area of functioning such as school work, sports ability or friendships?

Yes
No
Please make a selection.

21. How would you rate the parents' own anxiety levels when the child is feeling anxious on a scale of 1-10?

Mother 1 2 3 4 5 6 7 8 9 10 Select Father 1 2 3 4 5 6 7 8 9 10 Select

22. How would you rate the frustration levels of the parents when the child is feeling anxious on a scale of 1-10?

Mother 1 2 3 4 5 6 7 8 9 10 Select Father 1 2 3 4 5 6 7 8 9 10 Select

23. How would you describe your child's general temperament when they are not feeling particularly anxious? (please tick all that apply)

Happy and confident
Boisterous and active
Talkative and engaged
Quiet and thoughtful
Shy and hesitant
Generally nervous all the time

24. What do you think underlies your child's difficulty? (please tick all that apply)

Genuine fear
Irrationality
Stubborness
Wish to control the situation
Other - Please describe

25. How do you feel about your child's anxiety issues?(please tick all that apply)

Relaxed
Anxious
Angry
Worried
Frustrated
Desperate

26. Please give a brief statement (up to 100 words) of any other information you feel is relevant to your child's anxiety difficulties

Please type here...