social anxiety disorder
TODAY IS:
CONFIDENTIAL ASSESSMENT

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REQUIRED: Please enter your first and last name to complete the assessment.

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FIRST NAME

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LAST NAME

1.

2.

Fear that you will be humiliated by your actions

3.

Knowing that your fear is excessive or unreasonable

4.

Does a feared situation cause you to always feel anxious?

5.

Do you experience panic attacks during which you suddenly are overcome by an intense fear of discomfort including:

  • Pounding Heart

  • Sweating

  • Trembling

  • Chest Pain

  • Nausea or abdominal discomfort

  • Dizziness

  • Fear of losing control or "going crazy"

  • Fear of dying

  • And/or tingling sensations

6.

Do you go to great lengths to avoid participating?

7.

Do your symptoms interfere with your daily life?

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