SAnxiety scale and background factor questionnaire (long) - Social Anxiety Forum
 
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SAnxiety scale and background factor questionnaire (long)


This consists of two parts: an interaction/performance anxiety scale and a background/environmental factor questionnaire. This is very long but may offer some insight in to why you are the way you are.

Part 1: Interpersonal, social, sensitivity and heterosexual anxiety scale(107 questions).

SECTION 1: Interpersonal anxiety and shyness scale (36 questions)

(1) Being friendly with other people is:

(a) easy and natural 0
(b) can be difficult in some instances 1
(c) difficult and requires a lot of effort and nerve 2
(d) very difficult and takes a lot of effort and nerve 3
(e) impossible 4

(2) Making friends with someone whom I would like to be friends with is:

(a) easy and natural 0
(b) difficult and requires effort and nerve 1
(c) very difficult 2
(d) almost impossible 3
(e) impossible 4

(3) When someone starts a casual, friendly conversation with me I feel:

(a) relaxed 0
(b) slightly uncomfortable 1
(c) moderately uncomfortable 2
(d) very uncomfortable 3
(c) I want to just get away as quickly as possible 4

(4) Starting a casual, friendly conversation with someone I don't know is:

(a) easy 0
(b) slightly difficult 1
(b) difficult 2
(c) very difficult 3
(c) impossible 4

(5) When someone attempts to be friendly and get to know me I am:

(a) friendly 0
(b) slightly anxious and tense 1
(c) moderately anxious and tense 2
(d) very anxious and tense 3
(e) unfriendly and hostile 4

(6) I can easily relax around others even if they are all unfamiliar to me.

(a) always 0
(b) often 1
(c) difficult 2
(d) very difficult 3
(e) never 4

(7) Meeting new people makes me nervous and tense.

(a) false 0
(b) true to some extent 1
(c) true to a large extent 2

( I find new and unfamiliar social settings and situations:

(a) non-threatening 0
(b) slightly threatening 1
(c) moderately threatening 2
(d) very threatening 3
(e) unsettling 4

(9) When I am amongst other people and I want to say something I will:

(a) always speak up 0
(b) sometimes hold back because I don't have the nerve 1
(c) often hold back because I don't have the nerve 2
(d) almost always hold back because I just havn't the nerve 3
(e) always hold back because I don't have any nerve 4

(10) If I am eating dinner amongst a group of people and I want something out of my reach I would rather do without it than have to ask someone to pass it over to me simply because I lack the nerve to ask.

(a) false 0
(b) sometimes 1
(c) often 2
(d) very often 3
(e) always 4

(11) If someone is blocking a doorway and facing away from my direction and I want to get through I would rather wait for them to get out of the way than have to say "excuse me".

(a) false 0
(b) sometimes 1
(c) often 2
(d) very often 3
(e) always 4

(12) I just don't have the nerve to voice my opinion or speak up in situations that I have a right to and feel I should.

(a) never 0
(b) occasionally 1
(c) often 2
(d) very often 3
(e) always 4

(13) There have been times when someone has spoken to me and I have failed to reply because I just didn't seem have the nerve to speak for some reason.

(a) never 0
(b) a few 1
(c) quite a few 2
(d) a lot 3
(e) many 4

(14) I feel awkward and inept in casual, friendly social situations.

(a) never 0
(b) sometimes 1
(c) often 2
(d) very often 3
(d) always 4

(15) I am more relaxed and am able to function better in social situations that have structure rather than ambiguity and unpredictability.

(a) false 0
(b) true 1

(16) I find I have nothing to say or simply don't know what to say when amongst a group of people.

(a) never 0
(b) occasionally 1
(c) often 2
(d) very often 3
(d) always 4

(17) I feel very worried about having little or nothing to say to other people.

(a) never 0
(b) sometimes 1
(c) often 2
(d) very often 3
(d) always 4

(1 I am very worried about what others think of me when I am amongst a group of people.

(a) never 0
(b) sometimes 1
(c) often 2
(d) very often 3
(d) always 4

(19) Going up to a group of people and attempting to join in is:

(a) easy and natural 0
(b) slightly difficult 1
(b) difficult and require nerve and effort 2
(c) very difficult and requires a lot of nerve and effort 3
(d) impossible 4

(20) If a group of people asked me to join them I would:

(a) join in straight away 0
(b) hesitate but join in any way 1
(c) hesitate and say no and make up an excuse as to why I can't 2
(d) greatly hesitate and say no or make up an excuse 3
(e) ignore them and/or just walk off 4

(21) I feel uncomfortable and self-concious when people question me about my weekend, my social life, my interests, or ask me personal questions.

(a) never 0
(b) sometimes 1
(c) often 2
(d) very often 3
(d) always 4

(22) I experience great worry and try to avoid situations where others could potentially find out about any problems my social anxieties and social avoidance has caused me (example: spending large amounts of time at home, lack of social and romantic relationships...).

(a) never 0
(b) sometimes 1
(c) often 2
(d) very often 3
(e) always 4

(23) I worry people will reject or criticize me because of the way I am or if they find out about something I think they wouldn't like about me.

(a) no 0
(b) occasionally 1
(c) often 2
(d) very often 3
(e) always 4

(24) I find displaying, expressing or talking about my feelings and emotions to others:

(a) easy 0
(b) slightly difficult 1
(c) moderately difficult 2
(d) very difficult 3
(e) impossible 4

(25) The thought of self-disclosure about anything personal vis-a-vis someone I don't really know all that well makes me:

(a) feel nothing really 0
(b) feel slightly uncomfortable 1
(c) feel moderately uncomfortable 2
(d) feel very uncomfortable 3
(e) cringe 4

(26) I am socially inhibited and feel "shy" in:

(a) no situations at all 0
(b) only in new situations or around people that I am not used to 1
(c) in a lot of situations even with people I am used to 2
(d) in most situations even with people I am used to 3
(e) in all situations even with people I am used to 4

(27) I hold back information or would lie on a test or questionnaire just to avoid others thinking ill of me.

(a) never 0
(b) sometimes 1
(c) often 2
(d) very often 3
(e) always 4

(2 I try to be as "normal" and "mainstream" as possible just to avoid possible attention from others.

(a) never 0
(b) sometimes 1
(c) often 2
(d) very often 3
(e) always 4

(29) In an interpersonal relationship I feel self-conscious and/or inadequete for any reason or for no apparant or particular reason at all:

(a) never 0
(b) sometimes 1
(c) often 2
(d) very often 3
(e) always 4

(30) I prefer to work in an environment where I do not have to interact or socialize much with other people because I feel uncomfortable and self-conscious.

(a) false 0
(b) true to some extent 1
(c) true to a large extent 2

(31) I feel awkward and inept even in formal social settings.

(a) never 0
(b) sometimes 1
(c) often 2
(d) very often 3
(d) always 4

(32) I like to show others my abilities and what I'm good at.

(a) all the time 0
(b) usually 1
(c) not really 2
(d) mostly not 3
(e) definetely not 4

(33) I have troubling dealing with any interpersonal anxieties I may have in a constructive and appropriate manner.

(a) never 0
(b) sometimes 1
(c) often 2
(d) very often 3
(e) always 4

(34) My tolerance for interpersonal anxiety is:

(a) adequete 0
(b) slightly low 1
(c) moderately low 2
(c) significantly low 3
(d) almost non-existant 4

(35) The best way to deal with my fears and anxieties is to:

(a) confront and deal with them 0
(b) make an attempt to adapt 1
(c) avoid a lot of them 2
(d) avoid most of them 3
(e) avoid all of them 4

(36) I find experiencing interpersonal anxiety for whatever reason excruciatingly painful and I try to avoid it as much as possible.

(a) false 0
(b) true to some extent 1
(c) true to a large extent 2


Maximum score out of 135.

0 - 19 = You are not at all shy or just a little bit.
You experience nil or very little interpersonal anxiety.

20 - 39 = You are slightly shy.
You experience moderately levels of interpersonal anxiety.

40 - 59 = You are rather shy.
You seem to experience a fair amount of interpersonal
anxiety and quite often.

60 - 79 = You are a very shy.
Interpersonal anxiety levels are rather high and experienced
frequently.

80 - 99 = You are excessively shy.
Interpersonal anxiety is experienced very often and is
very high.

100 - 135 = You are extremely shy.
Interpersonal anxiety is extreme and experienced
excessively.

Chances are, if you score high up on interpersonal anxiety and shyness, you will also score high up in the following section.


SECTION 2: Some other questions that may be of some importance (13 questions)

(1) Saying "hello" to someone I know on the street or in a shop, only to discover it is the wrong person would be:

(a) not much of a big deal 0
(b) slightly worrying and quite embarassing 1
(c) moderately worrying and embarassing 2
(d) very worrying and embarassing 3

(2) Saying "hello" or "good morning" to someone and not getting a reply is:

(a) not much of a big deal to me 0
(b) slightly humiliating 1
(c) quite humiliating 2
(d) very humiliating 3

(3) I find I am far more easily put to shame, embarrassed or unsettled by seemingly trivial and insignificant remarks or events than most other people.

(a) false 0
(b) true to some extent 1
(c) very to a large extent 2

(4) I'd rather avoid doing something than risk making a fool of or embarassing myself.

(a) false 0
(b) true 1

(5) After I have an argument with someone I tend to feel anxious, tense and self-concious around them:

(a) never 0
(b) sometimes 1
(c) often 2
(d) always 3

(6) When someone blows their horn at me on the road I:

(a) pass it off 0
(b) feel rather shaken up and hurt by it 1
(c) feel unsettled and will often brood about it for the rest of the day 2

(7) I often mispercieve others to be annoyed or angry at me because I can normally pick up on a very slight tone of annoyance or anger in their voice.

(a) false 0
(b) true 1
(c) very true 2

( I often get angry at others, but don't really show it, if I percieve them as angry or annoyed with me.

(a) false 0
(b) true, sometimes 1
(c) true, often or always 2

(9) I find interpersonal conflict and hostility:

(a) unpleasant but nothing I can't really handle 0
(b) slightly unpleasant 1
(c) moderately unpleasant 2
(d) very unpleasant 3
(e) unbearable 4

(10) I would rather give-in or say it's my fault than get into any sort of argument with another person.

(a) false 0
(b) true, most of the time 1
(c) true, all of the time 2

(11) I am often afraid to make other people angry.

(a) false 0
(b) true 1

(12) When I am rejected, criticised, negatively evaluated, or scolded for any reason I will in most cases:

(a) quickly pass it off 0
(b) feel hurt by it but get over it quickly 1
(c) feel very hurt by it, and will brood on it and seethe 2
(d) react with low self-esteem, criticize myself or feel intense anger at the
other person 3

(13) Experiencing embarassment and humiliation is one of my worst fears.

(a) false 0
(b) true 1

Maximum score of 29.

0 - 5 = you are not very sensitive or just a bit
6 - 11 = you are a bit sensitive
12 - 16 = you are rather sensitive
17 - 21 = you are very sensitive
22 - 29 = you are extremely sensitive


SECTION 3: Social anxiety/social phobia questionnaire (35 questions)

(1) If I was invited to a party or a casual get-together that I really wanted to go to I would:

(a) always go 0
(b) worry about it a bit but still go 1
(c) worry about it but still go if I knew there was alcohol being served 2
(d) I would go but would need to be already intoxicated beforehand 3
(c) I would avoid it in all cases even if there was alcohol 4

(2) I avoid friendly and casual socializing because of what my anxiety could possibly make me do in front of others or how it could make me be seen by others.

(a) never 0
(b) sometimes 1
(c) often 2
(d) very often 3
(e) always 4

(3) Waiting in a line with other people behind me often makes me feel anxious and self-concious.

(a) false 0
(b) true to some extent 1
(c) true to a large extent 2

(4) Approaching a cashier behind the counter to pay for an item can be:

(a) not a problem 0
(b) slightly nerve-inducing 1
(c) quite nerve-inducing 2
(d) very nerve-inducing 3
(e) gut-wrenching 4

(5) Walking outside in the front garden of my house makes me anxious and self-conscious.

(a) no 0
(b) a little 1
(c) quite a bit 2
(d) very much 3
(e) I avoid it as much as possible 4

(6) I am afraid of driving in unfamiliar areas or roads because I am afraid I will make a mistake on the road and other drivers will blow their horns at me and I will look like an idiot.

(a) false 0
(b) true to some extent 1
(c) true to a large extent 2

(7) Talking or performing in front of a crowd or a group of people is:

(a) not a big deal 0
(b) slightly difficult 1
(c) difficult 2
(d) very difficult 3
(e) a nightmare 4

( Making a phone call is:

(a) not at all a problem 0
(b) a bit worrying 1
(c) rather worrying 2
(d) very worrying 3
(e) impossible 4

(9) Being closely observed by others while working or engaged in some activity:

(a) is not a problem for me 0
(b) makes me feel slighty on-edge and a little self-concious 1
(c) makes me feel rather on-edge and I become quite self-concious 2
(d) makes me very on-edge and very self-conscious 3
(e) makes me experience great anxiety and great self-consciousness 4

(10) When I make a social mistake or embarass myself I:

(a) quickly get over it 0
(b) find it difficult to get over it for many hours 1
(c) find it difficult to stop thinking and worrying about it for many days 2
(d) swear and scold myself for it and will be unable to stop worrying about
it for days 3
(e) can't worrying about it and will feel unable to return to the place where
it occured 4

(11) In the past I have avoided accepting dates and continually do so because I would be too afraid to go through with it.

(a) false 0
(b) true 1

(12) Dating is:

(a) great! 0
(b) a little nerve-racking 1
(c) rather nerve-racking 2
(d) very nerve-racking 3
(e) extremely nerve-racking 4

(13) Because of my social anxiety I haven't left the house for:

(a) the past few days 0
(b) the past few weeks 1
(c) the past few months 2
(d) the past few years 3
(e) more than five years 4

(14) I don't think I will be able to move out of my parents' house because of my social anxiety.

(a) false 0
(b) I'm not really sure 1
(c) possibly 2
(d) looks likely 3
(e) definetely 4

(15) Even though I would like to work and know I should, but because of my social anxiety I haven't worked:

(a) for a few weeks 0
(b) for a few months 1
(c) for a few years 2
(d) for more than five years 3
(e) in my entire life 4

(16) A job interview is:

(a) not a big deal 0
(b) slightly difficult 1
(c) difficult 2
(d) very difficult 3
(e) a nightmare 4

(17) Doing everyday tasks like shopping, paying bills, going to the bank, etc, is difficult because of my social anxiety.

(a) no 0
(b) a little bit 1
(c) quite a bit 2
(d) very much so 3
(e) unable to do it 4

(1 If I had only 6 months left to live I would:

(a) be able to bypass any social anxieties I may have and do what I want 0
(b) most likely bypass any fears and just do what I want 1
(c) quite likely will be unable to get over or face my fears 2
(d) very unlikely will be unable to get over or face my fear 3(e) I would rather die than have to face my fears 4

(19) I experience worry when I have to face one of my feared social situations.
(a) not at all 0
(b) a little bit 1
(c) a lot 2
(d) a great lot 3
(e) a tremendous amount and the only thing I can think about until I go
through with it 4

(20) I have dropped out of school, university, or work because of my anxiety.

(a) false 0
(b) true 1

(21) I often become anxious and self-conscious just walking past people on the street or other places.

(a) false 0
(b) true 1

(22) I find going out just about anywhere or any place anxiety-provoking.

(a) false 0
(b) true 1

(23) Eating in public or in front of others makes me self-conscious.

(a) no 0
(b) slightly 1
(c) quite a bit 2
(d) very much 3
(e) so much so that I avoid it 4

(24) I try to go out of my way to avoid other talking to me or even being seen by others.

(a) never 0
(b) occasionally 1
(c) often 2
(d) very often 3
(e) always 4

(25) In casual, friendly social situations I tend to feel self-conscious and anxious when I don't talk because I think others are thinking negative things about my lack of speech.

(a) never 0
(b) occasionally 1
(c) often 2
(d) very often 3
(e) always 4

(26) If I am walking in a shopping complex and I happen to see someone I know but don't ever talk to from school or from work I will start feeling anxious and self-conscious.

(a) not at all 0
(b) a little bit 1
(c) quite a bit 2
(d) very much 3
(e) I simply avoid them because it becomes too much 4

(27) The thought of losing my job is very nerve-racking because I will anticipate that I will have to go through the whole process of looking for another job and going through the whole interview thing, meeting new people, driving to a new place, ect.

(a) false 0
(b) true to some extent 1
(c) true to a large extent 2

(2 The thought of my next car service, or my car breaking down makes me very anxious because I will know I have to take it to a mechanic and will have to talk and interact with him/her.

(a) false 0
(b) true to some extent 1
(c) true to a large extent 2

(29) The thought of having an accident or getting really sick and having to go to the hospital makes me very anxious.

(a) false 0
(b) true to some extent 1
(c) true to a large extent 2

(30) If I am in a shopping centre or department store and I really wanted to buy somthing I would avoid doing so because I would be too afraid of what other people would think about me because of what I bought.

(a) never 0
(b) occasionally 1
(c) often 2
(d) very often 3
(e) always 4

(31) Using a toilet (including my own), or even flushing a toilet makes me uncomfortable when other people are near.

(a) never 0
(b) occasionally 1
(c) often 2
(d) very often 3
(e) always 4

(32) Blushing, shaking or stammering in my feared social situation is humiliating and makes me feel exposed and inferior.

(a) false 0
(b) true to some extent 1
(c) true to a large extent 2

(32) My social anxiety prevents me from getting any sort of help or seeing a therapist for it.

(a) no 0
(b) yes 1

(33) I feel I need to consume alcohol or drugs in order to do or go through just about anything that provokes my social anxiety.

(a) never 0
(b) sometimes 1
(c) often 2
(d) always 3

(34) I find watching tv with other people, including members of my family uncomfortable.

(a) no 0
(b) a little bit 1
(c) a lot 2
(d) I avoid it 3

(35) Because of my anxiety and avoidance patterns I have how many friends:

(a) many 0
(b) a few 1
(c) zero 2


Maximum score is 113.

0 - 19 you have very little or no social anxiety
20 - 39 you have only a low level of social anxiety
40 - 59 you suffer from a substantial level of social anxiety
60 - 79 you are suffering from a high amount of social anxiety
80 - 99 social anxiety is very high and bogging down your
personal freedom
100 - 113 your social anxiety is debilitating, unusually excessive
and extreme


SECTION 4: Heterosexual social/interpersonal anxiety and shyness scale (23 questions)

(1) Being friendly with the opposite sex is:

(a) easy and natural 0
(b) can be slightly difficult and takes some nerve and effort 1
(c) can be rather difficult requiring substantial nerve and effort 2
(c) very difficult and requires a lot of effort and nerve 3
(d) almost impossible or impossible 4

(2) Making an assertive move in the initiating of a romantic relationship or an overture towards someone I feel attracted to or would like to date is:

(a) easy and natural 0
(b) can be slightly difficult taking some nerve and effort 1
(c) rather difficult and takes quite a substantial level of nerve and effort 2
(c) very difficult and requires a lot of effort and nerve 3
(d) impossible 4

(3) If I had a dance or party to go to and I needed/wanted a partner and I had the phone number of an available person I knew from my university I would be able to call that person up: (this assumes there is no anxiety relating to making an actual phone call itself)

(a) always 0
(b) I would slightly hesitate 1
(c) I would be rather hesitant 2
(d) I would be very hesitant 3
(e) I would not be able to do it 4

(4) Whenever a person of the other gender whom I find quite attractive makes causal friendly conversation with me I am:

(a) calm and relaxed 0
(b) slightly tense and nervous 1
(c) rather nervous and tense 2
(d) very nervous and tense 3
(e) unsettled 4

(5) If I was among a group of same-sexed friends and a group of opposite-sexed people joined in I would:

(a) be able to keep talking to my friends and talk to the other gender as
well 0
(b) would only continue talking to my same-sexed friends 1
(c) would become rather quiet or would stop talking altogether 2

(6) If someone asked me to ask an opposite-sexed person in my university class for the time I would:

(a) be able to ask in any case 0
(b) hesitate but still ask 1
(c) greatly hesitate and try to find an excuse not to ask 2
(d) refuse to ask 3

(7) Whenever an attractive member of the opposite sex initiates a conversation with me or asks me a question I seem to always blush and feel self-conscious.

(a) never 0
(b) true to a small extent 1
(c) true to a large extent 2

( If I was at a dance with a group of friends and they all got up and asked for a dance with someone of the other gender I would also do the same.

(a) yes, or only if I wanted to 0
(b) would find it difficult 1
(c) wouldn't be able to do it 2

(9) Even though I would like to I have not been in a single romantic relationship in my entire life because my general anxieties regarding interpersonal interaction with members of the other sex and my inability to risk rejection in starting a conversation with someone of the other gender whom I am interested in and in asking for a date has blocked me from making any sort of effort and progress.

(a) false 0
(b) true 1

(10) I have been in a romantic relationship but only becuase the other person had initiated it.

(a) false 0
(b) true 1

(11) I am still a virgin not by choice but because of my heterosexual interaction anxieties:

(a) false 0
(b) true 1

(12) Due to my heterosexual anxieties I have only had sex a few times and only under the influence of alcohol and/or drugs.

(a) false 0
(b) true 1

(13) Starting a casual, friendly conversation with somone of the opposite sex is:

(a) easy and natural 0
(b) slightly difficult 1
(c) rather difficult 2
(d) very difficult 3
(e) impossible 4

(14) Whenever an attractive member of the opposite sex stares at me I am able to look back:

(a) always 0
(b) I can make one or a few quick non-direct glances 1
(b) never 2

(15) Whenever an attractive member of the opposite sex shows interest in me I tend to feel awkward and ill-at-ease.

(a) never 0
(b) to a small extent 1
(c) to a large extent 2

(16) I was uncomfortable and timid with the other gender ever since:

(a) never 0
(b) after age 12 1
(c) between age 8 and 12 2
(d) before age 8 3

(17) I thought this type of problem with the other gender was only a stage that I would pass through but many years later I find I am still like this.

(a) false, I got over it 0
(b) I am still like this 1
(c) I am worse than I was when I was younger 2

(1 I feel confident and comfortable when the other gender is present or around.

(a) yes, always 0
(b) no, rarely 1
(c) no, never 2

(19) The thought of having my feelings disclosed towards someone of the other gender that I like makes me:

(a) feel good or I'm not bothered by it 0
(b) a little worried 1
(c) rather worried 2
(d) very worried 3
(e) cringe 4

(20) I find friendly, casual conversations with the other gender that I do not feel attracted to:

(a) easy and natural 0
(b) a little uneasy and awkward 1
(c) rather uneasy and awkward 2
(d) very uneasy and awkward 3

(21) There has been a time when someone of the opposite sex that I like has asked me out and I refused because I felt way too afraid or awkward to say yes.

(a) never 0
(b) yes, once 1
(c) more than once 2

(22) I have been to various therapists and have tried various therapeutic methods to help me get over my fear of taking risks with the other gender but so far they have done little or nothing to help and the homework exercises set are totally unreasonable and require me to walk through fire in order to be healed.

(a) false 0
(b) true 1

(23) On last count I have had how many casual, friendly conversations with the other gender.

(a) too many to count 0
(b) a few 1
(c) not very many 2
(d) none 3


Total score out of 57.

0 - 9 = you have nil to very little heterosexual anxiety and shyness
10 - 19 = you are rather shy and inhibited with the other gender
20 - 29 = you are very shy and uncomfortable with the other gender
30 - 57 = you are extremely shy and anxious with the other gender


Part 2: Questionnaire for possible environment CASUAL ANTECEDENTS for social/interpersonal anxiety (182 questions).

A single characteristic, experience or event in a person's life could never on its own cause chronic interpersonal and social anxieties to develop. However, with a certain quantity and quality of characteristics, negative experiences and events occuring in a person's life, severe and chronic anxieties relating to human interaction and performance could be deemed as quite possible to develop and to debilitate that person's later adult life. Learning adds up in a cumulative fashion and each and every experience in a person's environment can in a way be seen as a learning experience that builds upon the last one. Further, learning experiences don't simply remain totally independent; they interact with one another in a synergistic way through casual association.

Note: this has been largely designed around my own chilhood experiences and designed purely for educational purposes only and is in no way designed to be a predictor or indicator of maladjustment later on in adulthood.


SECTION 1: SOME PERSONAL CHARACTERISTICS (17 questions)

(1) As a young child I was:

(a) never shy in any situation even with unfamiliar people 0
(b) slightly shy with unfamiliar people and/or new situations 1
(c) very shy with unfamiliar people and/or in new situations 2

(2) On my first day of elementary school I was:

(a) not at all nervous or anxious 0
(b) slightly nervous and anxious 1
(c) very nervous and anxious 2

(3) When I had to leave my mother behind because I began to go to elementary school I would cry.

(a) no 0
(b) yes 1

(4) For a while when I first started elementary school, out in the schoolyard at lunchtime I felt afraid and/or would cry because everything was knew and seemed threatening.

(a) no 0
(b) yes 1

(5) On my first day of high school I was:

(a) not at all nervous or anxious 0
(b) slightly nervous and anxious 1
(c) very nervous and anxious 2

(6) My parents have made comments about or have told me I was a quiet baby:

(a) false 0
(b) true 1

(7) Going up for "show and tell" back at elementary school was:

(a) not a problem for me 0
(b) slightly distressing 1
(c) distressing 2

( I tended to be the quietest person or one of the quietest people in my class when I was a young child at elementary school:

(a) false 0
(b) true 1

(9) I seem to be able to remember more things about my childhood than most other people seem to be able to.

(a) false 0
(b) true 1

(10) As of now, thinking about an embarassing or unpleasant event in my past, or a past social mistake that happened many years or even decades ago can cause me to experience fits and bouts of anxiety.

(a) false 0
(b) true 1

(11) When one of my parents threatened to punish me, yelled at or actually punished me for doing something wrong or for misbehaving I would in most instances be how afraid to do the same thing again.

(a) a little bit but would still have the courage to do it again anyway 0
(b) afraid and wouldn't do it again 1
(c) very afraid or I wouldn't dare do it again 2

(12) The first time I was threatened by another kid at a school I was in attendance to I was:

(a) not afraid or a little bit 0
(b) afraid 1
(c) very afraid 2

(13) If I am criticized or scolded for making a mistake by someone I will tend to feel:

(a) not at all hesitant or afraid at making the same mistake again or only
slightly 0
(b) hesitant and afraid to make the same mistake again 1
(c) very hesitant and very afraid to make the same mistake again 2

(14) If I criticize or scold someone for making a mistake I will be how afraid to commit the same type of mistake in the presense of that person.

(a) not really concerned or just a little bit worried 0
(b) quite worried and afraid 1
(c) very worried and very afraid 2

(15) I tend to be a competitive person.

(a) true 0
(b) false 1

(16) If someone says "hello" to me and I for some reason don't reply back (due to lack of attention for example) and I realize I didn't reply back I will tend to:

(a) shrug it off 0
(b) feel slightly ashamed and a bit worried about it 1
(c) feel rather ashamed and quite worried about it 2

(17) It seemed that everytime I had to return back to school after the summer or christmas holidays I would feel nervous or anxious in the morning upon returning to school.

(a) never 0
(b) a little bit 1
(c) quite a lot 2


Maximum score is 27.

The higher the score the greater the chances of developing later adjustment problems.



SECTION 2: PARENTS (43 questions)

(1) As a child if I did something wrong I would in most instances:

(a) sit down with my parents and talk about what I did 0
(b) be shown or expressed annoyance or frustration 1
(b) be shown annoyance or frustration and get shouted at or told off 2

(2) As a child I had corporal punishment (including use of objects like belts, sticks, ect) used on me:

(a) never 0
(b) a few times or occasionally 1
(c) many times or often 2

(3) When I recieved corporal punishment I would sometimes have my pants pulled down.

(a) no 0
(b) yes 1

(4) If I accidently dropped something or broke something my parents would in most instances:

(a) never or rarely show or express annoyance or frustration 0
(b) express annoyance or frustration 1
(c) express annoyance or frustration and would punish me 2

(5) As a child, if I was crying for something seemingly insignificant (like losing a toy) my parents would in most instances:

(a) comfort me 0
(b) tell me to grow up or something similar 1
(c) shout at me, tell me off or ignore me 2

(6) As a child there has been a time when I really wanted something and my parents refused to buy it.

(a) no or maybe once 0
(b) a few times 1
(c) more than a few times 2

(7) I have been criticized, scolded, shouted at, punished or smacked by one of my parents in front of other adults and/or children.

(a) never 0
(b) once or twice 1
(c) more than twice 2

( There has been a time when I was crying or displaying some emotion and at least one of my parents ridiculed, mocked, belittled or disparaged me for it, either in a serious or a non-serious manner.

(a) never 0
(b) once 1
(c) more than once 2

(9) As a child at least one of my parents has directed at me unusally loud and angry temper outbursts for misbehaviour.

(a) never 0
(b) occasionaly or a few times 1
(c) often or many times 2

(10) As a child at least one of my parents has directed at me very loud and angry outbursts of temper for little or no reason.

(a) never 0
(b) occasionaly or a few times 1
(c) often or many times 2

(11) As a child there has been a time when at least one of my parents have told me or forced me to behave or act in a certain way when I was not misbehaving or doing anything wrong.

(a) never 0
(b) once 1
(c) more than once 2

(12) As a child there has been a time when at least one of my parents were not interested in something I wanted to tell them or show them.

(a) never 0
(b) once 1
(c) more than once 2

(13) There has been a time when I was excited or proud about something that I had done (for example, getting a high score on a test) and I was expecting my parents to be proud of what I had to tell them but the reaction was rather "cool".

(a) never 0
(b) once 1
(c) more than once 2

(14) There has been a time when I had done my best at something (such as school work)and at least one of my parents told me that I could have done better or they were disappointed.

(a) never 0
(b) once 1
(c) more than once 2

(15) As a child if I really wanted to watch a movie that was recommended for a more mature audience my parents would let me watch it:

(a) always or almost always 0
(b) very rarely or never 1

(16) There has been a time when at least one of my parents made a promise to buy me something or to do something for me only to break that promise.

(a) never or maybe once 0
(b) twice 1
(c) more than twice 2

(17) My mother had a baby which died within the first week of being born.

(a) never 0
(b) once or more times 1

(1 As a child my mother was an irritable, high-strung, and/or depressed woman who was prone to outbursts of temper or rage.

(a) no 0
(b) kind of 1
(c) yes 2

(19) As a child I would talk or answer back to at least one of my parents:

(a) never or very rarely 0
(b) many times 1
(c) almost all the time or always 2

(20) Even though my parents have on occasions told me that they love me, how many times as a child did I actually feel a sense of happiness, well-being and pride knowing that my parents loved me and I loved them back.

(a) many times 0
(b) rarely 1
(c) never 2

(21) As of now now I actually feel loved by my parents, and I have felt that sense of well-being of feeling loved by them and loving them as well.

(a) on many occasions 0
(b) rarely 1
(c) never 2

(22) I can remember how many times as a child both my parents telling me that they love me.

(a) many times 0
(b) rarely 1
(c) never 2

(23) I can remember as a child and/or teenager how many times telling my parents that I love them.

(a) on many occasions 0
(b) a few times 1
(c) never 2

(24) As a child and/or teenager there has been a time when I have had an argument with one of my parents and the next time we spoke to each other we each were behaving and speaking to each other as if the argument had never happened and it was never resolved or spoken of again.

(a) never 0
(b) once 1
(c) twice or more times 2

(25) As a child I would engage in casual, friendly conversations or discuss things with my parents how often:

(a) everyday or almost everyday 0
(b) sometimes 1
(c) rarely, hardly ever or never 2

(26) As a teenager I would engage in casual, friendly conversations and discuss things with my parents how often:

(a) everyday or almost everyday 0
(b) sometimes 1
(c) rarely, hardly ever or never 2

(27) As a child, if I didn't finish eating all of my dinner I would in most instances:

(a) would not get into any sort of touble or shown any displeasure 0
(b) be criticized or shown annoyance or frustration 1
(c) be criticized, shown annoyance or frustration, and pressured into
finishing it 2

(2 As a child if I had a problem at school or something other and I felt like discussing it with my parents I would hesitate to talk to them about it.

(a) never or almost never 0
(b) a few times or occasionally 1
(c) many times, often or always 2

(29) As a child whenever I was given something by an adult or asked for something, my parents would tell me to say "please" and "thank you".

(a) only until I learned to do it automatically 0
(b) most or all the time, even when I knew I had to say it 1
(c) most or all the time and in a stern or threatening manner 2

(30) As a child if I really wanted to stay up late on a school night for a particular or special reason my parents would let me stay up.

(a) most of the time or always 0
(b) rarely 1
(c) never 2

(31) Even as an older child if I wanted to meet some friends after school somewhere or walk to a friends' house which was just a few blocks away in order to just to hang out my parents would let me.

(a) always or almost always 0
(b) rarely 1
(c) never 2

(32) As a child if I wanted to play out in the street my parents would tell me to stay in an area where they could see me.

(a) never or very rarely 0
(b) occasionally or a few times 1
(c) many times or often 2

(33) There has been a time when I have been told off or punished for disobeying my parents in regards to the above question.

(a) no 0
(b) yes, once 1
(c) more than once 2

(34) As a child there has been a time when I did something wrong and I got told off for it by one of them, I felt ashamed or embarrassed for it and one of my parents mentioned to me about how I blushed or how I looked embarrassed or told me "look at what you have done to yourself".

(a) never 0
(b) this has happened once or more times 1

(35) As a child there has been a time when one of my parents threatened to harm me in a rather brutal way when they were angry with me (such as knock my teeth out or knock my head off my shoulders).

(a) never 0
(b) very rarely or a few times 1
(c) quite often or many times 2

(36) As a child there has been a time when I have angered one of my parents and my other parent got upset with him/her for getting angry with me and I got blamed, scolded, or punished for causing an argument between them.

(a) never 0
(b) once 1
(c) more than once 2

(37) As a child and teenager at least one of my parents was rather nosy and disrespectful regarding my privacy and when it came to my own personal business.

(a) never 0
(b) sometimes 1
(c) often 2

(3 There has been a time when I felt angry, or some sort of emotion towards one of my parents but didn't show it and they told me that they know what I am feeling and can see it and told me off or criticized me for feeling like that.

(a) never 0
(b) once 1
(c) more than once 2

(39) There has been a time when I was somewhat rude or non-curtious towards a stranger or an adult only to have one of my parents criticize me or tell me off or forced me to apologize.

(a) never 0
(b) once 1
(c) more than once 2

(40) There has been a time when I said something to one of my parents that made them upset and some time down the track they said the same thing to me and I saw it as hypocritical.

(a) never 0
(b) once or more times 1

(41) As a child I had hurt myself because I was doing something silly and at least one of my parents refused to help me in order to teach me a lesson.

(a) never 0
(b) once 1
(c) more than once 2

(42) If I was eating dinner at the table and if the tv was on I would be told off if I paid attention to it.

(a) false 0
(b) true 1

(43) As a child I have been forced my at least one of my parents to go on holiday programs.

(a) never 0
(b) once 1
(c) more than once 2


Maximum score is 80.

Note: even though it seems low, a score of 30 (or more) is considered very risky in terms of later developmental problems.



SECTION 2: PEER GROUP AND SCHOOL LIFE (65 questions)

Note: questions marked with ** are to also be answered regarding high school.


**(1) At elementary school I would be physically bullied and harassed by at least one child.

(a) never 0
(b) occasionally or a few times 1
(c) many times or often 2

**(2) At elementary school I was intimidated or threatened with violence or made to feel afraid by at least one other child.

(a) never 0
(b) occasionally or a few times 1
(c) many times or often 2

(3) During my first year at elementary school I was physically bullied, harassed and/or intimidated and threatened with violence or made to feel afraid by at least one other child.

(a) never 0
(b) occasionally or a few times 1
(c) many times or often 2

**(4) At elementary school I would be teased, sworn at or made fun of by at least one child.

(a) never 0
(b) occasionally or a few times 1
(c) many times or often 2

**(5) Negative (or what I perceived as negative) comments about me being a quiet person and/or my timidity and shyness were made by other children in my elementary school.

(a) never 0
(b) once or twice 1
(c) more than twice 2

**(6) Negative comments about my personal appearence (clothes, hair style, ect) or some physical characteristic (such as the way I talked or how my voice sounded, how I walked, how I tended to behave or act (for example: dopey or clumsy, ect), the size or shape of my head, ect) were made by other children in my elementary school or outside of school.

(a) never 0
(b) once or twice 1
(c) more than twice 2

**(7) At elementary school I would be left out of activities by the other children and/or not chosen for activities by the other children.

(a) never 0
(b) occasionally 1
(c) often or always 2

**( At elementary school I was popular with a lot or most other kids.

(a) true 0
(b) false 1
(d) false and rather unpopular 2

**(9) At any one time at elementary school I had how many close friends whom I felt comfortable about discussing just about anything with and would always listen to me if I had something to say.

(a) 3 or more 0
(b) 1 or 2 1
(c) none 2

**(10) At elementary school I would have people to hang around or play with at lunchtime.

(a) always 0
(b) most of the time 1
(c) rarely or never 2

**(11) Even though I had people to hang around with at elementary school I felt somewhat disliked or disrespected by some of them in some way.

(a) never 0
(b) rarely or on a few occasions 1
(c) many times or quite often 2

**(12) Even though I had people to hang around with at elementary school I felt left out or not really wanted or apart of the group.

(a) never 0
(b) rarely or on a few occasions 1
(c) many times or quite often 2

**(13) There have been times when other kids would let me hang around them in elementary school but only because I would do almost anything they would tell me to do.

(a) false 0
(b) true 1

**(14) I made friends how quickly at elementary school.

(a) on the first day or within a week at the most 0
(b) it took a great deal longer to make friends than the other children 1
(c) I never made any friends 2

**(15) I had how many really deep and meaningful conversations with other children (including any friends) at elementary school.

(a) many or often 0
(b) rarely or a few 1
(c) very rarely or none 2

**(16) Most of my friendships with other children I used to talk to and hang around with at elementary school were quite superficial and/or rather meaningless.

(a) false 0
(b) true to some extenet 1
(c) true to a large extent 2

**(17) There has been a time when I was good friends with someone at elementary school only to have an argument or fight with them.

(a) never 0
(b) once or twice 1
(c) more than twice 2

**(1 There has been a time when I was friends with someone at elementary school only to have an argument or fight with them and we never spoke to one another again or only after a rather long time.

(a) never 0
(b) once 1
(c) more than once 2

**(19) There has been a time when I thought I was friends with someone at my elementary school only to discover they didn't really like me or as much as I thought they did.

(a) no 0
(b) once 1
(c) more than once 2

**(20) There has been a time when I was best friends with someone at my elementary school only to have someone else come along and take my place.

(a) no 0
(b) once 1
(c) more than once 2

**(21) There has been a time when I felt betrayed, was decieved, or lied to by one someone whom I thought I was friends with when I was at elementary school.

(a) never 0
(b) once 1
(c) more than once 2

**(22) There has been a time when I wanted to join in a group of kids at my elementary school only to be told to leave or go away.

(a) never 0
(b) once 1
(c) more than once 2

**(23) There has been a time when I was excluded, expelled from or told to go away by a friend or group of friends at my elementary school because of something that I did or said or for no apparent reason at all.

(a) no 0
(b) once 1
(c) twice 2
(d) more than twice 3

**(24) The people I hung around with at elementary school would tease me or make jokes about me.

(a) never 0
(b) rarely or on the odd occasion 1
(c) quite a few times or often 2

**(25) At elementary school I was forced to do something shameful or embarassing or that would get me into trouble in front of other children just for their entertainment.

(a) never 0
(b) once 1
(c) twice or more 2

**(26) I had my pants pulled down or an attempt was made by another child to pull my pants down in front of other children at elementary school.

(a) never 0
(b) once 1
(c) twice or more 2

**(27) There was one or more children at my elementary school who genuinely hated me and would sometimes or often go out of his/her way to express that hatred for me physically and/or with words.

(a) false 0
(b) true 1

**(2 I had how many friends outside of elementary school that I would also often hang around with:

(a) many 0
(b) a few 1
(c) none 2

**(29) During elementary school I was invited to and went to how many birthday parties or other sorts of parties that did not involve my family or kin.

(a) many 0
(b) a few 1
(c) very few or none 2

**(30) During elementary school I had how many birthday parties which I invited other children to.

(a) most or all of my birthdays I had parties which involved other children 0
(b) two or three 1
(c) one or none 2

**(31) There has been a time when I was deliberately ignored by another kid or a group of kids at my elementary school just to make me feel left out or because they just didn't like me.

(a) never 0
(b) once 1
(c) twice or more 2

**(32) I would hang out after school or on the weekend with the people I hung around with at elementary school.

(a) always or often 0
(b) not very often 1
(c) hardly ever or never 2

**(33) I felt I never really fitted in with most of the other children at my elementary school or was a kind of oddball or clown.

(a) false 0
(b) true to some extent 1
(c) true to a large extent 2

**(34) At elementary school there was at least one kid I would have to pay money to otherwise I would be threatened or physically assaulted by him/her in some way.

(a) false 0
(b) true but only once or twice 1
(c) true and it happend many times or often 2

**(35) Whenever I was around other children outside of elementary school (such as a holiday camp or program) I would be either disparaged, belittled, teased, sworn at, and/or physically bullied by at least one other child.

(a) never happened 0
(b) happened occasionally or a few times 1
(c) happened a lot or many times 2

**(36) Negative comments were made about me for having few or no friends by other children in my elementary school.

(a) false 0
(b) true or on a few occasions 1
(c) true and quite often 2

**(37) There has been a time when one kid at my elementary school would stare at me in a way that was intimidating and/or degrading and designed to deliberately damage my self-esteem, make me feel humiliated or to make me feel afraid.

(a) never 0
(b) once 1
(c) more than once 2

**(3 Whenever there was a free or casual dress day at my elementary school I would.

(a) always wear casual clothes 0
(b) sometimes or occasionally wear casual clothes 1
(c) hardly or never wear casual clothes 2

**(39) At elementary school I tripped or fell over in front of other people.

(a) never 0
(b) once 1
(c) more than once 2

**(40) Whenever I was physically assaulted by another kid at my elementary school I would fight back.

(a) all the time or never had to because no one did those things to me 0
(b) sometimes 1
(c) hardly ever or never 2

**(41) Whenever I was physically assaulted by another kid at my elementary school I would tell the teacher.

(a) all the time or never had to because no one did those things to me 0
(b) sometimes 1
(c) hardly ever or never 2

**(42) At elementary school some of the kids forced me or told me to behave or act in a certain way because they simply didn't like how I was behaving.

(a) never 0
(b) once 1
(c) more than once 2

**(43) There has been a time when I had an argument or fight with one of my friends at elementary school and the next time we saw or spoke to each other we both were pretending as if it had never happened and it was never resolved or spoken of again.

(a) never 0
(b) once 1
(c) twice or more times 2

**(44) There has been a time when I attempted to be funny or to make a joke only to have another child or some other children deflate my ego or say something that made me feel stupid or humiliated.

(a) never 0
(b) once 1
(c) more than once 2

**(45) I was physically bullied and assaulted by how many children during my time at elementary school.

(a) zero 0
(b) one or two 1
(c) three or four 2
(d) more than five 3

**(46) I was sworn at, teased or made fun of by how many children during my time at elementary school:

(a) zero 0
(b) one or two 1
(c) three or four 2
(d) more than five 3

**(47) There has been a time when I accidently hurt another child at my elementary school and I was intimidated, threatened or assaulted by another kid for doing so.

(a) never 0
(b) once or more times 1

**(4 There has been a time when I asked to borrow a pen or something from another student only to have him/her tell me no or worse.

(a) never 0
(b) once 1
(c) more than once 2

**(49) There has been a time when I was told off, scolded or criticized in front of my friends and/or other children at my elementary school by another child's parent or some other adult other than a teacher

(a) never 0
(b) once 1
(c) more than once 2

**(50) There has been a time when a teacher at my elementary school forced me to apologize for something I did or said to the whole class or in some way humiliate me for my misbehaviour.

(a) never 0
(b) once 1
(c) more than once 2

**(51) There has been a time when I was rather harshly criticized, scolded, or punished by one of the teachers at my elementary school for something I did wrong or for talking in class.

(a) never 0
(b) once or twice 1
(c) more than twice 2

**(52) There has been a time when one of my elementary teachers told or forced me to behave or act in a certain way even though I was not misbehaving or doing anything wrong or breaking any rules.

(a) never 0
(b) once or more times 1

**(53) There has been a time when I asked for help by one of my elementary school teachers only to have that teacher help out another student first.

(a) never 0
(b) once 1
(c) once or more times 2

**(54) There has been a time when I had to go to the toilet at elementary school only to have the teacher tell me I have to wait until lunchtime.

(a) never 0
(b) once or twice 1
(c) more than twice 2

**(55) There has been a time when I wanted help for something from my elementary school teacher only to have them say no or tell me to ask someone else or to attempt it myself.

(a) never 0
(b) once 1
(c) more than once 2

**(55) At least one of my elementary school teachers would treat me as the black sheep of my class or would give me a label (a daydreamer for example).

(a) never 0
(b) a few times or occasionally 1
(c) many times or often 2

**(56) At elementary school I would be made to sit in the corner for misbehaviour how many times.

(a) never 0
(b) once or twice 1
(c) more than twice 2

**(57) There has been a time when one of the other children at my elementary school made something up about me and I got into trouble for it.

(a) never 0
(b) once 1
(c) once or more times 2

**(5 During elementary school there has been a time when I was at a friends house and was told to leave by one of the parents.

(a) never 0
(b) once 1
(c) more than once 2

**(59) There has been a time when I was criticized, told off or scorned by one of my friends' parents for something I did or said wrong.

(a) never 0
(b) once 1
(c) more than once 2

**(60) There has been a time when I have been asked by another child or other children at my elementary school things like "how come your so quiet ?", "how come you never talk ?", or "why don't you talk much ?".

(a) never 0
(b) once 1
(c) twice or more 2

**(61) There has been a time when I was asked questions about my life outside of school by others at my elementary school and I was criticized or ridiculed or made out as weird for being different to them or most other kids (the norms).

(a) never 0
(b) once or twice 1
(c) more than twice 2

**(62) There has been a time when I was told by another kid or group of kids to not hang around someone or group of people because they didn't like that person or group of people.

(a) never 0
(b) once 1
(c) more than once 2

**(63) There has been a time when I was spat on by another student at my elementary school.

(a) never 0
(b) once 1
(c) more than once 2

**(64) There has been a time when I heard some other students whispering things about me in elementary school.

(a) never 0
(b) once 1
(c) more than once 2

**(65) There has been a time when another student at my elementary school imitated my words or actions in a way designed to damage my self-esteem.

(a) never 0
(b) once 1
(c) more than once 2


Add your score up for the questions related to elementary school.
Maximum score is 131.

Add up you score for the questions related to high school.
Maximum score is 129.

Add up both of your total scores.
Maximum score is 260.

Note: apart from a few questions, many of these experiences may have happened or also happened outside of elementary school and high school. If so, pick the appropriate answer and add it to your score for this section. This may take your total score above the maximum of 260.

Note: even though it may seem low, a score of above 40 (or more) for elementary school is considered very risky in terms of development of later adjustment problems. A score of above 100 for both elementary school and high school would be considered highly likely that later problems would occur regarding social and interpersonal interactions in later adulthood.


SECTION 3: SIBLINGS AND EXTENDED FAMILY (28 questions)

(1) As a child I had how many other adults besides my parents who I could count on or turn to for support.

(a) three or more 0
(b) one or two 1
(c) none 2

(2) As a child at least one of my grandparents would threaten to smack me for misbehaviour.

(a) false 0
(b) true 1

(3) As a child I was smacked by one of my grandparents.

(a) never 0
(b) once or more times 1

(4) As a child whenever I dropped some food on the floor, at least one of my grandparents would in most instances:

(a) help me to clean it up or simply tell me to clean it up but in a nice way 0
(b) criticize me, or express annoyance or frustration 1

(5) As a child I felt close to my grandparents and felt that they cared about me.

(a) true 0
(b) false 1

(6) As a child my grandparents told me that they love me how many times.

(a) on many occasions 0
(b) hardly ever or never 1

(7) Even as a child I have often felt uncomfortable of being around one of my grandparents.

(a) false 0
(b) true 1

( As a child I got along how well with most of my cousins.

(a) rather well 0
(b) ok 1
(c) not very well or not at all 2

(9) As a child everytime I saw one of my cousins it would be comfortable and easy to talk and play with them:

(a) all the time 0
(b) most of the time 1
(c) not very often or not at all 2

(10) As a child there has been a time when at least one of my cousins has disparaged me, belittled me, or made fun of me.

(a) never 0
(b) a few times or occasionally 1
(c) many times or often 2

(11) As a child even though I had a sibling who I got along quite well with, whenever a cousin was around, I would in most instances feel excluded or ignored by that sibling.

(a) never 0
(b) a few times or occasionally 1
(c) many times or often 2

(12) There have been times when I had a cousin (or cousins) ask me things like "how come you don't talk ?" or "why don't you talk ?", or "how come you're so quiet ?".

(a) never 0
(b) once or twice 1
(c) more than twice 2

(13) As a child even though I had a sibling who I got along quite well with, whenever a cousin would say something negative about me, my sibling would join in.

(a) never 0
(b) a few times or occasionally 1
(c) many times or often 2

(14) As a child I had an uncle or auntie comment on my shyness or quietness.

(a) never 0
(b) once or twice 1
(c) more than twice 2

(15) As a child I was scolded or told off by an uncle or auntie for misbehaviour.

(a) never 0
(b) once or twice 1
(c) more than twice 2

(16) As a child I felt how close to my uncles and aunties.

(a) quite close to at least some of them 0
(b) not all that close to any of them 1

(17) As a child I had an uncle or auntie threaten to smack me.

(a) never 0
(b) once 1
(c) more than once 2

(1 As a child everytime I saw an uncle or auntie I would talk to them and discuss things with them.

(a) always or almost always 0
(b) sometimes or not often 1
(c) very rarely or never 2

(19) I saw my uncles and aunties and cousins how often.

(a) often 0
(b) not too often 1
(c) hardly ever 2

(20) As a child my parents' brothers and sisters got along how well with one another.

(a) rather well and few if any arguments 0
(b) ok but there would be some arguments 1
(c) not that well and many arguments 2

(21) As a child I was physically assaulted by a sibling.

(a) never 0
(b) once 1
(c) twice or more 2

(22) I have been harshly and unjustly criticized or scolded for making an insignificant or trivial mistake by a sibling.

(a) never 0
(b) once 1
(c) more than once 2

(23) As a child I had how many arguments and fights with a sibling.

(a) a few or not that many 0
(b) quite a few 1
(c) a lot 2

(24) As a child one of my siblings has told me that he/she would harm or even kill me for some reason.

(a) never 0
(b) once or more times 1

(25) I have been given a label by one of my siblings (such as dopey, loser ect)

(a) never 0
(b) a few times 1
(c) many times 2

(26) I have been picked on or teased by one of my siblings' elementary and/or high school friends.

(a) never 0
(b) a few times 1
(c) many times 2

(27) As a child there has been a time when I was belittled or disparaged by a sibling in front of other children.

(a) never 0
(b) once 1
(c) more than once 2


(2 I never had any siblings and I scored above 30 on the last section.

(a) false 0
(b) true 1


Maximum score is 47.

The higher the score the more likely that problems will develop.


SECTION 4: Some further questions that may be of some importance in the development of chronic social/interpersonal anxiety (13 questions).

(1) As a child there has been a time when I was with a parent at a shopping centre or department store and we both or myself, or my parent walked through a security scanner only to set it off.

(a) never 0
(b) once or more times 1

(2) There has been time as a child teenager when I was in a newsagency reading a magazine and one of the people over there kept looking in my direction because I was in there for a long time.

(a) never 0
(b) once 1
(c) more than once 2

(3) There has been a time as a child when I was in a shop or department store and told to leave for some reason by one a person working over there.

(a) never 0
(b) once or more times 1

(4) As a child or there has been a time when I have been told off by someone working in a store for touching stuff I wasn't allowed to.

(a) never 0
(b) once 1
(c) once or more times 2

(5) There was one time when I was a young child in a shopping centre or department store and I got lost or seperated from my parents and I felt very afraid and didn't know what to do.

(a) never 0
(b) once or more times 1

(6) As a child there has been a time when I was corrected, criticized, scolded or threatened by a stranger in front of my parents or family or when I was alone for doing something wrong.

(a) never 0
(b) once 1
(c) more than once 2

(7) As a child there has been a time when I had picked something up in a public place or store only to have that person tell me in a stern vioce to "put that down" or "put that back".

(a) never 0
(b) once 1
(c) more than once 2

( There has been a time when, as a child, I have been told to smile simply because I wasn't smiling or had a kind of frown.

(a) never 0
(b) a few times 1
(c) many times 2

(9) There has been a time when I was just sitting up at the front of the class in elementary or high school and I started blushing for some reason and felt really self-concious about it.

(a) never 0
(b) once or twice 1
(c) more than twice 2

(10) When I was a young child at school I accidently urinated and/or defecated in my pants while in the classroom and I was made to clean it up by an angry teacher.

(a) never 0
(b) once or more times 1

(11) As a child my parents would tell me about the dangers of strangers.

(a) never 0
(b) yes, a few times 1
(c) yes, many times 2

(12) As a child I would watch tv shows like rescue 911 and that involved crimes such as kidnappings, home invasions, ect.

(a) never 0
(b) yes, a few times 1
(c) yes, many times 2

(13) As a child, being alone and around a stranger would make me feel somewhat fearful and weary about the motives and intentions of that stranger.

(a) never 0
(b) occasionally or a few times 1
(c) often or many times 2

(14) Even as of now, whenever I hear a knock on the door I react with fear.

(a) false 0
(b) true 1


Maximum score is 23.

The higher the score the higher the risk in developing later problems.


SECTION 4: Questions that may be of some importance in the development of heterosexual interpersonal anxieties (16 questions)

(1) I grew up with how many siblings around that were of the other gender:

(a) two or more 0
(b) one 1
(c) none 2

(2) The parent of the opposite gender to myself did most of the punishing in my house.

(a) false 0
(b) true 1

(3) I saw and an interacted with cousins of the other gender:

(a) frequently or many times 0
(b) rarely or only a few times 1
(c) very rarely or never 2

(4) At elementary school I interacted and talked to the other gender in my class.

(a) frequently or many times 0
(b) occasionally or a few times 1
(c) very rarely or never 2

(5) I was beaten up, physically assaulted or bullied by someone of the other gender of a similar age as me a child either at elementary school or outside of it:

(a) never 0
(b) once or more times 1

(6) There was at least one opposite-sexed student in my elementary school that didn't like me all that much.

(a) false 0
(b) true, but only one 1
(c) true, and more than one 2

(7) There was a time when I was infatuated with or felt attracted to a girl in my elementary school and she would at times call me names or pick on me, or has criticized me for any reason.

(a) false 0
(b) true 1

( At elementary school at least one person of the other gender would swear at or give me a hard time.

(a) never 0
(b) a few times 1
(c) many times 2

(9) I was romantically interested in the other gender from the age of:

(a) 8 or older 0
(b) 6 or 7 1
(c) 5 or younger 2

(10) I became sexually curious and had sexual fantasies about the other gender at the age of:

(a) 11 or older 0
(b) 7, 8, 9 or 10 1
(c) 5 or 6 2
(d) before age 5 3

(11) I was exposed to or looked at pornography at age:

(a) 11 or older 0
(c) 7, 8, 9, or 10 1
(d) 5 or 6 2
(c) before age 5 3

(12) Before the age of 12 I have been told off and/or punished by at least one of my parents or by someone else for looking at pornography or having a sexual interest/curiosity in the other gender.

(a) never 0
(b) once 1
(c) more than once 2

(13) At elementary school I was always unusually uncomfortable compared to the other children about undressing or taking my clothes off (for example, when having to change into bathers for swimming lessons).

(a) false 0
(b) true to some extent 1
(c) true to a large extent 2

(14) I discovered the joys and pleasures of masturbation at the age of:

(a) 11 or older 0
(b) 7, 8, 9, or 10 1
(c) 5 or 6 2
(d) before age 5 3

(15) At elementary school there has been a time when someone has criticized or scolded me for expressing or talking about doing something sexual to an opposite-sexed student.

(a) false 0
(b) true 1

(16) There has been a time when I have deliberately hurt another member of the other gender as a child and got punished or told off for it.

(a) false 0
(b) true 1

Maximum score is 30.

The higher the score the higher the chances of developing problems with the other gender.


Maximum score for all sections is 467.
A score of between 200 - 250 is considered very risky in regards to developmental of social/interpersonal functioning.
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post #2 of 7 (permalink) Old 05-10-2008, 09:40 PM Thread Starter
 
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Posts: 490

Re: SAnxiety scale and background factor questionnaire (long)


Ahhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhh hhhhhhhhhhhhhhhhh. Needed a positive reaction from others...no response...starting to feel the humiliation and shame creep in...starting to experience anxiety...beginning to think about never posting something on here again just incase I don't get a response...starting to think maybe it was just another ingrained maladaptive way of thinking...starting to clam down...realized it was a rather long post...realized most people don't have as much time on their hands as I do...starting to think I am a tragic loser for having so much time on my hands...starting to think I am quite different from most others even those with SA...shame begins to creep in...anxiety levels beginning to rise...
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post #3 of 7 (permalink) Old 05-10-2008, 09:58 PM
 
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Re: SAnxiety scale and background factor questionnaire (long)


Quote:
Originally Posted by Pinzelhead
Ahhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhh hhhhhhhhhhhhhhhhh. Needed a positive reaction from others...no response...starting to feel the humiliation and shame creep in...starting to experience anxiety...beginning to think about never posting something on here again just incase I don't get a response...starting to think maybe it was just another ingrained maladaptive way of thinking...starting to clam down...realized it was a rather long post...realized most people don't have as much time on their hands as I do...starting to think I am a tragic loser for having so much time on my hands...starting to think I am quite different from most others even those with SA...shame begins to creep in...anxiety levels beginning to rise...
Thanks for posting. I haven't done the whole thing because I am too lazy to get up and get a pencil to keep track (;, but i looked through it and did the last section and got a 9 on that section. Where did you find it? Are there any guidelines to the scores? I don't want to answer all those questions and then not know what my score means. But it was illuminating answering the questions I did, and seeing the scores for the different answers. Because I didn't realize that some of those things might contibute to my sa with girls.
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post #4 of 7 (permalink) Old 05-10-2008, 10:00 PM
 
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Re: SAnxiety scale and background factor questionnaire (long)


oh and I don't think that a lack of responses necessarily = a negative response on a sa site lol.
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post #5 of 7 (permalink) Old 05-10-2008, 10:05 PM Thread Starter
 
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Re: SAnxiety scale and background factor questionnaire (long)


just thought I would post a typical thought/emotional reaction process I go through when feeling rejected.
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post #6 of 7 (permalink) Old 05-10-2008, 10:29 PM
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Re: SAnxiety scale and background factor questionnaire (long)


holy ****. i can't be half assed to do all of that. what is that, like 300 questions?
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post #7 of 7 (permalink) Old 05-10-2008, 11:25 PM
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Re: SAnxiety scale and background factor questionnaire (long)


I think it's kind of long and the results are nothing new to me, but I took it anyways, cause I figured one person should do it.

Part 1:
First: 65
Second: 11
Third: 26
Forth: 26

Part 2:
First: 7
Second: 19
Third: 37
Forth: 5
Fifth: 5
Sixth: 2

A grand total of 203.

For anyone else that might take it. It's easier if you just open another window and use the calculator. Then, just write down your results in your original window(this reply section).
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