Donore NS Child Anxiety Survey for Parents
This survey is to help with the school's SSE programme in improving the subject of SPHE in the school and children's experience of anxiety. This survey is completely anonymous and we thank you for taking your time to fill it out.
Child's Class
Please chose your child's class
1. Worries about performing, "falling short:, being inadequate or "less than"
2. Is either anxious and / or afraid to look anxious performing around others (red aloud, speak in class, play sport, etc.)
3. Has sudden rapid and significant/dramatic increases in anxiety.
4. Is really bothered if things are not arranged correctly or in order.
5. Worries about being left somewhere (e.g. forgotten at school)
6. Is really afraid of certain animals, insects, reptiles and/or other living things
7. Asks for reassurance over and over about the same things(s)
8. Scared just thinking about going to school
9. Feeling overwhelmed and overly concerned about physical symptoms when anxious (rapid heart rate, dizziness, etc.)
10. Anxious about 1 or more of these: dirt, germs, viruses, poison, body fluids (faeces, blood, saliva, urine etc.) or other contaminants
11. Certain colours, numbers, or words cause distress
12. Is anxious and/or very shy meeting new people
13. Strongly prefers to sleep with someone at night. Doesn't like being alone.
14. Fears something turned out far worse than it actually did (test, performance, event)
15. Dreads experiencing panic or intense anxiety again.
16. Gets anxious about being embarrassed and/or criticised.
17. Expends a lot of effort cleaning and/or decontaminating (washing hands, shower clothes)
18. Frequent stomach aches/distress/nausea
19. Has to check multiple times on things that worry him/her (light switches, water taps, door locked)
20. Has trouble falling and/or staying asleep due to anxiety.
20. Has trouble falling and/or staying asleep due to anxiety.
21. Feels like can't get breath and/or heart pounding when anxious.
22. Confesses to things he/she didn't even do or are so minor no one cares.
23. Is worried about throwing up, gagging and or/choking.
24. Seems nervous, tense or "keyed up" most of the time.
25. Is extremely rule orientated (afraid of lying, stealing, leading someone astray, etc)
26. Is afraid of storms or other naturally occurring events ( tsunami, tornado, etc)
27. Avoid places/situations that could lead to anxiety.
28. Worries (and /or dreams) something bad will happen to parent or caregiver.
29. Will not wear things because it doesn't "feel" right
30. Is not eating enough and/or is very picky because of fear of getting sick
31. Ignores compliments/praise but treats criticism as "truth"
32. Complains of muscle aches/pains (eg. headaches) and being tired
33. Has to do something over and over again unit it feels complete and/or safe (tapping movements, turn things on and off, etc.)
34. Overly anxious with the thought of being separated from caregiver
35. Worries that his/her thoughts can cause harm and/or are especially shocking
36. Fears a specific thing like heights, small spaces, clowns, doctors etc.
37. Follows me around and/or wants to know exactly where I am.
38. Something about school escalates anxiety
39. Does your child have their own of any of the following (Please tick all that apply)
40. Does your child have access to any of the following (Please tick all that apply)
41. If your child does spend time on any of the above devices, to what extent would you say the time they spend on them is supervised?
42. Has your child ever come to you to discuss something/someone that has worried, confused or frightened them when using any of the above?
43. If your child spends regular time on any of the above devices please estimate the amount of time each day spent spend on such device - where they might spend more time at the weekend and less mid-week, just estimate a daily average (either supervised or unsupervised)
44. Any comments or reflections
Your answer
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.