Severity Measure for the Generalized Anxiety Disorder –Child Age 11-17

Name: PHOEBE RAFUNSEL S. JUYAD Age: 17

Gender : __ Male _✔️_ Female Date:11/07/20

Instructions: The following questions ask about thoughts, feelings and behaviour, often tied to
concerns about family, health, finances, school and work. Please respond to each item by
marking (check or X) one box per row.

During the PAST 7 DAYS I have.. Never Occasionall Half of Most All of Item
y the time of the the time Score
time
0 1 2 3 4 2

1. did you have moments of sudden terror, fear, or fright? ✔️

0 1 2 3 4 1
2. did you feel anxious, worried or nervous?
✔️
3. did you have feel tense muscle, feel on the edge or restless
or had trouble relaxing or sleeping?
0 1 2 3 4 1

✔️
4. did you leave situation early or participated minimally due
to worries?
0 1 2 3 4 1

✔️
5.did you feel the need to help cope with anxiety through
alcohol, meditation or superstitious objects?
0 1 2 3 4 0

✔️
total 5
Students with a having a total score of 16-20 points may be referred to the Guidance
Coordinator for further assessment and psychological intervention.