Social Phobia Questionnaire Pack

PHQ- 9
Over the last 2 weeks, how often have you been bothered by any More Nearly
Several
of the following problems? Not at all than half every
days
the days day
1 Little interest or pleasure in doing things 0 1 2 3
2 Feeling down, depressed, or hopeless 0 1 2 3

3 Trouble falling or staying asleep, or sleeping too much 0 1 2 3

4 Feeling tired or having little energy 0 1 2 3

5 Poor appetite or overeating 0 1 2 3

Feeling bad about yourself — or that you are a failure or have let
6 0 1 2 3
yourself or your family down
Trouble concentrating on things, such as reading the newspaper or
7 0 1 2 3
watching television
Moving or speaking so slowly that other people could have noticed?
8 Or the opposite — being so fidgety or restless that you have been 0 1 2 3
moving around a lot more than usual
Thoughts that you would be better off dead or of hurting yourself in
9 0 1 2 3
some way
A11 – PHQ9 total score

GAD-7
Over the last 2 weeks, how often have you been bothered by any More Nearly
Several
of the following problems? Not at all than half every
days
the days day

1 Feeling nervous, anxious or on edge 0 1 2 3

2 Not being able to stop or control worrying 0 1 2 3

3 Worrying too much about different things 0 1 2 3

4 Trouble relaxing 0 1 2 3
5 Being so restless that it is hard to sit still 0 1 2 3

6 Becoming easily annoyed or irritable 0 1 2 3

7 Feeling afraid as if something awful might happen 0 1 2 3

A12 – GAD7 total score

IAPT Phobia Scales

Choose a number from the scale below to show how much you would avoid each of the situations or objects
listed below. Then write the number in the box opposite the situation.
0 1 2 3 4 5 6 7 8
Would not Slightly Definitely Markedly Always avoid
avoid it avoid it avoid it avoid it it

A17 Social situations due to a fear of being embarrassed or making a fool of myself

Certain situations because of a fear of having a panic attack or other distressing symptoms (such
A18
as loss of bladder control, vomiting or dizziness)

Certain situations because of a fear of particular objects or activities (such as animals, heights,
A19
seeing blood, being in confined spaces, driving or flying).
IAPT Employment Status Questions
A13 - Please indicate which of the following options best describes your current status:

Employed full-time (30 hours or more per week)

Employed part-time
Unemployed
Full-time student
Retired
Full-time homemaker or carer

A14 - Are you currently receiving Statutory Sick Pay?

Yes
No

A15 - Are you currently receiving Job Seekers Allowance, Income support or Incapacity benefit?

Yes
No

Work and Social Adjustment

People's problems sometimes affect their ability to do certain day-to-day tasks in their lives. To rate your
problems look at each section and determine on the scale provided how much your problem impairs your
ability to carry out the activity.

1. WORK - if you are retired or choose not to have a job for reasons unrelated to your problem, please tick
N/A (not applicable)

0 1 2 3 4 5 6 7 8 N/A
Not at Slightly Definitely Markedly Very severely,
all I cannot work

2. HOME MANAGEMENT – Cleaning, tidying, shopping, cooking, looking after home/children, paying bills
etc

0 1 2 3 4 5 6 7 8
Not at Slightly Definitely Markedly Very severely
all

3. SOCIAL LEISURE ACTIVITIES - With other people, e.g. parties, pubs, outings, entertaining etc.

0 1 2 3 4 5 6 7 8
Not at Slightly Definitely Markedly Very severely
all

4. PRIVATE LEISURE ACTIVITIES – Done alone, e.g. reading, gardening, sewing, hobbies, walking etc.

0 1 2 3 4 5 6 7 8
Not at Slightly Definitely Markedly Very severely
all

5. FAMILY AND RELATIONSHIPS – Form and maintain close relationships with others including the people
that I live with

0 1 2 3 4 5 6 7 8
Not at Slightly Definitely Markedly Very severely
all

A14 – W&SAS total score

Social Phobia Inventory (SPIN)
Please check how much the following problems have bothered you during the past
week. Mark only one box for each problem, and be sure to answer all items.

Not at all A little Somewhat Very Extremely

bit Much
1. I am afraid of people in authority. 0 1 2 3 4

2. I am bothered by blushing in front of people. 0 1 2 3 4

3. Parties and social events scare me. 0 1 2 3 4

4. I avoid talking to people I don’t know. 0 1 2 3 4

5. Being criticized scares me a lot. 0 1 2 3 4

6. Fear of embarrassment causes me to avoid doing 0 1 2 3 4

things
or speaking to people.
7. Sweating in front of people causes me distress. 0 1 2 3 4

8. I avoid going to parties. 0 1 2 3 4

9. I avoid activities in which I am the centre of 0 1 2 3 4

attention.

10. Talking to strangers scares me. 0 1 2 3 4

11. I avoid having to give speeches. 0 1 2 3 4

12. I would do anything to avoid being criticized. 0 1 2 3 4

13. Heart palpitations bother me when I am around 0 1 2 3 4

people.

14. I am afraid of doing things when people might 0 1 2 3 4

be
watching.
15. Being embarrassed or looking stupid are my 0 1 2 3 4
worst fears.

16. I avoid speaking to anyone in authority. 0 1 2 3 4

17. Trembling or shaking in front of others is 0 1 2 3 4

distressing to
me.

J. R. Davidson 2000
 SOCIAL SUMMARY RATING SCALE

a) Please circle a number from the scale below that best describes how severe your social anxiety has been
in the last week:

0 1 2 3 4 5 6 7 8
Not at all Slightly Definitely Markedly Severely
disturbing disturbing disturbing disturbing disturbing
and/or and/or and/or and/or and/or
disabling disabling disabling disabling disabling

b) Please circle a number from the scale below to show how often in the last week you have avoided difficult
social situations or aspects of those situations.

0 1 2 3 4 5 6 7 8
Not at all Rarely Sometimes Often Always

c) For social situations in general, please choose a number from the scale below to show the extent to
which your attention was focused on yourself or on the external situation in the last week.

0 1 2 3 4 5 6 7 8
Entirely Both Entirely
externally equally self
focused focused

d) For social situations that you found difficult, please choose a number from the scale below to show the
extent to which your attention was focused on yourself or on the external situation in the last week.

0 1 2 3 4 5 6 7 8
Entirely Both Entirely
externally equally self
focused focused

e) Over the past week how often have you gone over in your mind things that you think might go wrong in a
social situation before entering the situation.

0 1 2 3 4 5 6 7 8
Not at all Rarely Sometimes Often Always

f) Over the past week how often have you gone over social interactions in your mind after they have
finished.

0 1 2 3 4 5 6 7 8
Not at all Rarely Sometimes Often Always
 SOCIAL COGNITIONS QUESTIONNAIRE

Listed below are some thoughts that go through people’s minds when they are nervous or frightened.

Indicate, on the LEFT hand side of the form, how often in the last week each thought has occurred; rate
each thought from 1-5 using the following scale:

1. Thought never occurs

2. Thought rarely occurs
3. Thought occurs during half of the times when I am nervous
4. Thought usually occurs
5. Thought always occurs when I am nervous

HOW OFTEN BELIEVE

___ I will be unable to speak ___
___ I am unlikeable ___
___ I am going to tremble or shake uncontrollably ___
___ People will stare at me ___
___ I am foolish ___
___ People will reject me ___
___ I will be paralysed with fear ___
___ I will drop or spill things ___
___ I am going to be sick ___
___ I am inadequate ___
___ I will babble or talk funny ___
___ I am inferior ___
___ I will be unable to concentrate ___
___ I will be unable to write properly ___
___ People are not interested in me ___
___ People won’t like me ___
___ I am vulnerable ___
___ I will sweat/perspire ___
___ I am going red ___
___ I am weird/different ___
___ People will see I am nervous ___
___ People think I am boring ___
Other thoughts not listed (please specify):
___
___

When you feel anxious how much do you believe each thought to be true. Please rate each thought by
choosing a number from the scale below, and put the number which applies on the dotted line on the RIGHT
hand side of the form.

0 10 20 30 40 50 60 70 80 90 100
I do not believe I am completely
convinced
this thought this thought is true

Developed by Adrian Wells, Lucia Stopa and David M Clark (1993)

Typed Jan 2000