Social Anxiety Screening Tool

Social Anxiety Screening Tool
This is a screening measure to help you determine whether you might have social
anxiety that needs professional attention. This screening tool is not designed to make a
diagnosis of social anxiety but to be shared with your primary care physician or mental
health professional to inform further conversations about diagnosis and treatment.
Directions:
1. Print out the form
2. Complete the provided form
3. Share them with your health care provider to determine a diagnosis
Are you troubled by the following?
☐ Yes ☐ No An intense and persistent fear of a social situation in which people

might judge you such as:
☐ Yes ☐ No Social interactions (e.g., having a conversation, meeting unfamiliar

people)
☐ Yes ☐ No Being observed (e.g., eating or drinking in public)
☐ Yes ☐ No Performing in front of others (e.g., giving a speech)
☐ Yes ☐ No Fear that you will act in a way or show anxiety symptoms that will be
negatively evaluated (i.e., will be humiliating or embarrassing; will lead
to rejection or offend others)
☐ Yes ☐ No Fear that people will notice that you are blushing, sweating, trembling,
or showing other signs of anxiety
☐ Yes ☐ No Perceiving that your reaction to feared situations to be greater than

most other people
Does a feared situation cause you to...
☐ Yes ☐ No always feel anxious?
☐ Yes ☐ No experience a panic attack, during which you suddenly are overcome by
intense fear or discomfort, including any of these symptoms:
☐ Yes ☐ No Pounding heart
☐ Yes ☐ No Sweating
☐ Yes ☐ No Trembling or shaking
☐ Yes ☐ No Choking
☐ Yes ☐ No Chest pain
☐ Yes ☐ No Trembling or shaking
☐ Yes ☐ No Nausea or abdominal discomfort
☐ Yes ☐ No "Jelly" legs
☐ Yes ☐ No Dizziness
☐ Yes ☐ No Feelings of unreality or being detached from yourself
☐ Yes ☐ No Fear of losing control or “going crazy”
☐ Yes ☐ No Fear of dying
☐ Yes ☐ No Numbness or tingling sensations
☐ Yes ☐ No Chills or hot flushes
☐ Yes ☐ No go to great lengths to avoid participating?
☐ Yes ☐ No have your symptoms interfere with your daily life?
Having more than one illness at the same time can make it difficult to diagnose and treat the
different conditions. Depression and substance abuse are among the conditions that
occasionally complicate social anxiety disorder.
☐ Yes ☐ No Have you experienced changes in sleeping or eating habits?
More days than not, do you feel…

☐ Yes ☐ No Sad or depressed?
☐ Yes ☐ No Disinterested in life?
☐ Yes ☐ No Worthless or guilty?

During the last year, has the use of alcohol or drugs...
☐ Yes ☐ No resulted in your failure to fulfill responsibilities with work, school, or
family?
☐ Yes ☐ No placed you in a dangerous situation, such as driving a car under the
influence?
☐ Yes ☐ No gotten you arrested?
☐ Yes ☐ No continued despite causing problems for you or your loved ones?
Reference: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC, American
Psychiatric Association, 1994.
During the last year, has the use of alcohol or drugs...

During the past six months, have you often been bothered by any of the following
symptoms? Check one square next to each symptom that you have had more days than
not:
Moderately
Quite a bit
Extremely
Not at all
A little
a. restlessness or feeling keyed         
up or on edge
b. Irritability         
c. difficulty falling/staying         
asleep or restless/unsatisfying
sleep
d. being easily fatigued         
e. difficulty concentrating or         
mind going blank
f. muscle tension         
How much do worry and physical symptoms interfere with your life, work, social
activities, family, etc.?
        
None Mild Moderate Severe Very
Severe
How much are you bothered by worry and physical symptoms (how much distress
does it cause you)?
        
None Mild Moderate Severe Very
Severe
Source: Newman, M. G., Zuellig, A. R., Kachin, K. E., Constantino, M. J., Przeworski, A., Erickson, T., &
Cashman-McGrath, L. (2002). Preliminary reliability and validity of the Generalized Anxiety Disorder
Questionnaire-IV: A revised self-report diagnostic measure of generalized anxiety disorder. Behavior
Therapy, 33, 215-233. doi:10.1016/S0005-7894(02)80026-0

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Social Anxiety Screening Tool

Are you troubled by the following?

☐ Yes ☐ No An intense and persistent fear of a social situation in which people

☐ Yes ☐ No Social interactions (e.g., having a conversation, meeting unfamiliar

☐ Yes ☐ No Being observed (e.g., eating or drinking in public)

☐ Yes ☐ No Performing in front of others (e.g., giving a speech)

☐ Yes ☐ No Perceiving that your reaction to feared situations to be greater than

Does a feared situation cause you to...

☐ Yes ☐ No always feel anxious?

☐ Yes ☐ No Pounding heart

☐ Yes ☐ No Chest pain

☐ Yes ☐ No Trembling or shaking

☐ Yes ☐ No Nausea or abdominal discomfort

☐ Yes ☐ No "Jelly" legs

☐ Yes ☐ No Feelings of unreality or being detached from yourself

☐ Yes ☐ No Fear of losing control or “going crazy”

☐ Yes ☐ No Fear of dying

☐ Yes ☐ No Numbness or tingling sensations

☐ Yes ☐ No Chills or hot flushes

☐ Yes ☐ No go to great lengths to avoid participating?

☐ Yes ☐ No have your symptoms interfere with your daily life?

☐ Yes ☐ No Have you experienced changes in sleeping or eating habits?

More days than not, do you feel…

☐ Yes ☐ No Disinterested in life?

☐ Yes ☐ No Worthless or guilty?

☐ Yes ☐ No gotten you arrested?

During the last year, has the use of alcohol or drugs...

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