Phobic Encounter Record

Current Symptoms Self-Report Form Week of:

Instructions: Complete a separate copy of this form each time you encounter your feared object or situation.

Date: Time:
Instructions: Please check the response next to each item that best describes your behavior during the past week.

Situation:
Never or
Rarely Sometimes Often Very Often

Fail to give close attention to details or make careless

1
mistakes in my work
Maximum fear (use a – point scale):
2 Fidget with hands or feet or squirm in seat
Main bodily sensations (check)
Have difficulty sustaining my attention in tasks or
3
fun activities
Racing heart Shortness of breath Dizziness/unsteadiness
Leave my seat in situations in which seating is
4 Chest tightness Nausea Sweating
expected

5 Don’t listen when spoken to directly

Trembling Numbness Choking
6 Feel restless
Hot/cold Sense of unreality
Don’t follow through on instructions and fail to
7
finish work Other feelings:
Have difficulty engaging in leisure activities or doing
8
fun things quietly

9 Have difficulty organizing tasks and activities

10 Feel “on the go” or “driven by a motor”

Avoid, dislike, or am reluctant to engage in work that

11
requires sustained mental effThoughts:
ort

12 Talk excessively

13 Lose things necessary for tasks or activities

Blurt out answers before questions have been

14 completed

15 Am easily distracted Behavior:

16 Have difficulty awaiting turn

17 Am forgetful in daily activities

18 Interrupt or intrude on others

From R. A. Barkley & K. R. Murphy (1998), Attention-Deficit Hyperactivity Disorder: A clinical workbook (2nd ed.). New York: Guilford Press.

Reprinted with permission.Mastery

Treatments That Work Mastering Your Fears and Phobias

TM

Copyright
Copyright © 2005© 2006 University
Oxford Oxford University
Press Press