Question |
Response |
1. |
Do you (or your child) experience recurrent, excessive distress when expecting to be away from home or from certain family members? |
|
2. |
Do you (or your child) worry excessively and frequently about losing family members or about harm that could come to them? |
|
3. |
Do you (or your child) worry excessively and frequently about getting lost, being kidnapped, or some other event that would cause separation from certain family members? |
|
4. |
Do you (or your child) feel reluctant or unwilling to go to school or other places because of fear of separation from certain family members? |
|
5. |
Are you (or your child) excessively and frequently fearful or reluctant to be alone or without certain family members, even at home? |
|
6. |
Do you (or your child) frequently feel reluctant or unwilling to go to sleep without being near certain family members or to sleep away from home? |
|
7. |
Do you (or your child) had repeated nightmares about being separated from home or certain family members? |
|
8. |
Do you (or your child) frequently experience or complain of physical symptoms (such as headaches, stomachaches, nausea, or vomiting) when anticipating separation from home or certain family members? |
|
9. |
Have these concerns lasted at least four weeks? |
|
10. |
Did these concerns begin before the age of 18? |
|
11. |
Do anxiety, worry, physical symptoms, or reluctance to be separated from certain family members cause you (or your child) to feel very distressed? |
|
12. |
Do anxiety, worry, physical symptoms, or reluctance to be separated from certain family members cause significant impairment in your (or your child's) social life, school, work, or other important areas of functioning? |
|