| 1. My child worries about things |
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| 2. My child feels sad or empty |
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| 3. When my child has a problem, he/she gets a funny feeling in his/her stomach |
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| 4. My child worries when he/she thinks he/she has done poorly at something |
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| 5. My child feels afraid of being alone at home |
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| 6. Nothing is much fun for my child anymore |
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| 7. My child feels scared when taking a test |
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| 8. My child worries when he/she thinks someone is angry with him/her. |
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| 9. My child worries about being away from me |
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| 10. My child is bothered by bad or silly thoughts or pictures in his/her mind |
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| 11. My child has trouble sleeping |
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| 12. My child worries about doing badly at school work |
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| 13. My child worries that something awful will happen to someone in the family |
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| 14. My child suddenly feels as if he/she can’t breathe when there is no reason for this. |
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| 15. My child has problems with his/her appetite |
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| 16. My child has to keep checking that he/she has done things right (like the switch is off, or the door is locked) |
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| 17. My child feels scared to sleep on his/her own |
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| 18. My child has trouble going to school in the mornings because of feeling nervous or afraid. |
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| 19. My child has no energy for things |
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| 20. My child worries about looking foolish |
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| 21. My child is tired a lot |
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| 22. My child worries that bad things will happen to him/her |
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| 23. My child can’t seem to get bad or silly thoughts out of his/her head. |
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| 24. When my child has a problem, his/her heart beats really fast |
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| 25. My child cannot think clearly |
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| 26. My child suddenly starts to tremble or shake when there is no reason for this |
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| 27. My child worries that something bad will happen to him/her |
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| 28. When My child has a problem, he/she feels shaky |
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| 29. My child feels worthless |
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| 30. My child worries about making mistakes |
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| 31. My child has to think of special thoughts (like numbers or words) to stop bad things from happening |
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| 32. My child worries what other people think of him/her |
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| 33. My child is afraid of being in crowded places (like shopping centers, the movies, buses, busy playgrounds) |
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| 34. All of a sudden my child will feel really scared for no reason at all |
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| 35. My child worries about what is going to happen |
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| 36. My child suddenly becomes dizzy or faint when there is no reason for this |
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| 37. My child thinks about death |
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| 38. My child feels afraid if he/she have to talk in front of the class |
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| 39. My childs heart suddenly starts to beat too quickly for no reason |
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| 40. My child feels like he/she doesnt want to move |
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| 41. My child worries that he/she will suddenly get a scared feeling when there is nothing to be afraid of |
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| 42. My child has to do some things over and over again (like washing hands, cleaning, or putting things in a certain order) |
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| 43. My child feels afraid that he/she will make a fool of him/herself in front of people |
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| 44. My child has to do some things in just the right way to stop bad things from happening |
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| 45. My child worries when in bed at night |
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| 46. My child would feel scared if he/she had to stay away from home overnight |
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| 47. My child feels restless |
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