Name: Age:

Date: Gender Male: Female:

OBJECTIVE:
Your health care provider is your first point of call to assess whether you might meet the
criteria to be diagnosed with social anxiety disorder. Your doctor will do an assessment to
determine if your symptoms are caused by any underlying physical health conditions. Your
doctor may then refer you to a psychiatrist or a psychologist who specializes in diagnosing
anxiety disorders.

INSTRUCTIONS:
Answer the 5 questions below for the test to see his ability to cause an issue in society. Study
each statement and answer it with your true feelings. Every question needs an answer.

No YES
•do you socialize with
others?
• Are you making eye contact
while they are talking to you?
• Are you concerned with
other people to give your
own opinion?
• Do you feel nervous when
facing a lot of people?
• Do you feel afraid when
people look at you?