Current Symptoms Self-Report Form

Week of:

Phobic Objects and Situations

nstructions: Please check the response next to each item that best describes your behavior during the past week.
Instructions: Make a check next to each specific object or situation in which you experience fear.

Once youve checked each object or situation that frightens you, put those items in order to indicate how important a priority it is for
treatment.
Your highest-priority item would be ranked ,
Never
or
your second-priority item would be ranked
,
and
so on. Only rank
the itemsVery
thatOften
you checked.
Rarely
Sometimes
Often
1

Type
Fail to give close attention to details
or make carelessCheck
mistakes in my workAnimals and Insects

Fidget with hands or feet or squirm in seat

Have diculty sustaining my attention in tasks or

fun activities

Leave my seat in situations in which seating is

expected

Dont listen when spoken to directly

Feel restless

Dont follow through on instructions and fail to

nish work

Have diculty engaging in leisure activities or doing

fun things quietly
X

Blood, Injection, or Injury

X
X
X

Natural Environment

Have diculty organizing tasks and activities

Situational

Specific Object or Situation

Dogs
Cats
Mice
Birds
Snakes
Spiders
Bugs
Other animal (
)
Blood
Needles
Doctors/hospitals
Dentists
Heights (e.g., balconies, ladders, bridges, ledges)
Dark
Thunder and lightning
Water
Closed in places (e.g., tunnels, elevators, small
rooms, stairwells)
Driving (e.g., on freeways, city streets, or in
poor weather)
Airplanes
Trains
Vomiting
Choking
Other (
)
Other (
)
Other (
)
Other (
)
Other (
)

10

Feel on the go or driven by a motor

11

Avoid, dislike, or am reluctant to engage in work that

requires sustained mental eort

12

Talk excessively

13

Lose things necessaryOther

for tasks or activities

14

Blurt out answers before questions have been

completed

15

Am easily distracted

16

Have diculty awaiting turn

17

Am forgetful in daily activities

18

Interrupt or intrude Example

on othersof Phobic Objects and Situations form

Figure 4.1

From R. A. Barkley & K. R. Murphy (1998), Attention-Decit Hyperactivity Disorder: A clinical workbook (2nd ed.). New York: Guilford Press.

Reprinted with permission.Mastery

Treatments That Work Mastering Your Fears and Phobias

TM

Copyright
Oxford
2006 Oxford
University
Press
Copyright
2005
University
Press

Rank

3
2
1