Name (Optional) :______________________ Section:______________ Sex: F M

RELIGION
Roman Catholic Protestant
Islam Born Again
Baptist Seventh Day Adventist
Iglesia ni Cristo Others:_________________

TYPE OF SCHOOL (JHS)

Private Sectarian
Private Non Sectarian
Public

Directions: The following sections describe your anxiety experiences on school related
activities/academics, family matters, and social aspects. Kindly place a check mark ( / ) under the
appropriate columns according to the following scale:

5 Panic - Level (inability to move or speak, impaired rational thinking, or distorted perception)
4 Severely Anxious (pounding heartbeat, chest pain, headache, vomiting, diarrhea,
trembling, scattered thoughts, erratic behavior, or sense of dread)
3 Moderately Anxious (faster heartbeat, dry mouth, sweating, stomach pain, or nausea)
2 Mildly Anxious( sweaty palms and heightened senses)
1 Not Anxious At All

SCHOOL RELATED ACTIVITIES/ACADEMICS: 5 4 3 2 1

I am anxious when it is the first day of class.
I am anxious when I get low grades.
I am anxious when I am in the verge of being late.
I am anxious when I am about to cheat in a test.
I am anxious when it is my turn to recite.

FAMILY MATTERS: 5 4 3 2 1
I am anxious when I get pressured by my parents to do well.
I am anxious when my parents get violent with each other.
I am anxious when I am being accused of doing something I
did not commit.
I am anxious when my parents talk about financial problems.

I am anxious when I am about ask for permission to hang out

with my friends.

SOCIAL ASPECTS: 5 4 3 2 1
I am anxious when I meet new faces.
I am anxious when I perform on stage.
I am anxious when someone I like notices me.
I am anxious when I go to crowded places alone.
I am anxious when I hear people talking about me.