SPDQ

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

SPDQ

Your birthdate and date of your first DBTCSD therapy session are needed for us to identify your data while keeping it anonymous to others. Your data will be transmitted securely as scrambled numbers without any text labels.

Birthday *

YYYY

Your name *

In the following questions you will find a set of difficulties and problems which possibly describe you. Decide how much you suffered from each problem during the course of the last week: 0 = not at all 1 = a little 2 = moderately 3 = quite a bit 4 = extremely

If you are uncertain, please answer according to how you think you might have felt. Please answer honestly. All questions refer to the last week. If you felt different ways at different times in the week, give a rating for how things were for you on average. Please be sure to answer each question.

In social situations where it is possible that you will be noticed or evaluated by other people, do you feel excessively nervous, fearful or uncomfortable? *

0 - No

1 - Yes

Do you tend to be overly worried that you may act in a way that might embarrass or humiliate yourself in front of other people, or that others may not think well of you? *

0 - No

1 - Yes

Do you try to avoid social situations? *

0 - No

1 - Yes

Below is a list of some situations that are fear provoking for some people. Rate the severity of your anxiety and avoidance on the following scales:

0 = No fear 0 = Never avoid
1 = mild fear 1 = Rarely avoid
2 = Moderate fear 2 = Sometimes avoid
3 = Severe fear 3 = Often avoid
4 = Very severe fear 4 = Always avoid

Parties

Fear

Avoidance

Clear selection

Meetings

Fear

Avoidance

Clear selection

Eating in a public location

Fear

Avoidance

Clear selection

Using public bathrooms when others are present

Fear

Avoidance

Clear selection

Becoming the focus of attention

Fear

Avoidance

Clear selection

Writing in front of other people (signing checks, filling out forms)

Fear

Avoidance

Clear selection

Dating circumstances

Fear

Avoidance

Clear selection

First dates

Fear

Avoidance

Clear selection

Speaking with people in authority

Fear

Avoidance

Clear selection

Saying "no" to unreasonable request

Fear

Avoidance

Clear selection

Asking someone to do something differently

Fear

Avoidance

Clear selection

Being introduced

Fear

Avoidance

Clear selection

Initiating a conversation

Fear

Avoidance

Clear selection

Keeping a conversation going

Fear

Avoidance

Clear selection

Giving a speech

Fear

Avoidance

Clear selection

Using the telephone

Fear

Avoidance

Clear selection

Others judging you

Fear

Avoidance

Clear selection

Others observing you

Fear

Avoidance

Clear selection

Being teased

Fear

Avoidance

Clear selection

Do you tend to experience fear each time you are in feared social situations

0 - No

1 - Yes

Clear selection

Does the fear come on as soon as you enter feared social situation?

0 - No

1 - Yes

Clear selection

Would you say that your social fear is excessive or unreasonable?

0 - No

1 - Yes

Clear selection

Select the degree to which your social fear interferes with your life, work, social activities, family, etc?

Not at all

Very severely

Clear selection

How distressing do you find your social fear?

Not at all

Very severely

Clear selection

Has what you have been able to achieve in your job or in school been negatively effected by your social fear?

0 - No

1 - Yes

Clear selection

Filled out by *

Client

Parent

Other

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of DBT San Diego. Report Abuse

Forms