Self-Consciousness Rating Form

Name: Date (from-to):

Instructions: The following form is used to record your estimates of the likelihood and degree of negative consequence associated with daily social experiences that
involve feelings of anxiety or distress. It is important to complete this form as soon after the social event as possible in order to maintain its accuracy.

Extent of Self-Focus Target of Self-Focus (list specific

(rate extent of focus on physical sensations, thoughts,
Describe difficult or anxious social situation (what Negative Consequence (describe
yourself from 0= no images, verbal expressions, or
Date happened, who was involved, where, what was your any negative impression that you
self-focus to 100 behavioral actions of which you
role?) might have made on others)
=completely self- were intensely aware in the social
absorbed) situation)
 Self-Consciousness Rating Form

Name: Date (from-to):

Extent of Self-Focus Target of Self-Focus (list specific

(rate extent of focus on physical sensations, thoughts,
Describe difficult or anxious social situation (what Negative Consequence (describe
yourself from 0= no images, verbal expressions, or
Date happened, who was involved, where, what was your any negative impression that you
self-focus to 100 behavioral actions of which you
role?) might have made on others)
=completely self- were intensely aware in the social
absorbed) situation)