Penn State Worry Questionnaire
Please take a moment to complete this questionnaire.
I prefer to respond anonymously:
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Fear Questionnaire (FQ)

Choose a number from the scale below to show how much you would avoid each of the situations listed below because of fear or other unpleasant feelings.

0 1 2 3 4 5 6 7 8
Would not avoid it                Slightly avoid it                Definitely avoid it                   Markedly avoid it                     Always avoid it

Main phobia you want treated, please describe...
1. Main Phobia you want treated - avoidance levels
                                   
2. Injections or minor surgery
                                   
3. Eating or drinking with other people
                                   
4. Hospitals
                                   
5. Travelling alone or by bus
                                   
6. Walking alone in busy streets
                                   
7. Being watched or stared at
                                   
8. Going into crowded shops
                                   
9. Talking to people in authority
                                   
10. Sight of blood
                                   
11. Being criticized
                                   
12.Going alone far from home
                                   
13, Thought of injury or illness
                                   
14. Speaking or acting to an audience
                                   
15. Large open spaces
                                   
16. Going to the dentist
                                   
17. Other Situations

Please describe the situation/s


18. How would you rate the scale of your phobic symptons on the scale below?

 

0 1 2 3 4 5 6 7 8
no phobias present                slightly disturbing/not really disabling                definitely disturbing/disabling                   markedly disturbing/disabling                     very severely disturbing/disabling

                                   
Now choose a number from the scale below to show how much you are troubled by each problem listed.

 

0 1 2 3 4 5 6 7 8
hardly at all                slightly troublesome                definitely troublesome                   markedly troublesome                     very severely troublesome

19. Feeling miserable or depressed
                                   
20. Feeling irritable or angry
                                   
22. Upsetting thoughts coming into your head
                                   
23. Feeling you or your surroundings are strange or unreal
                                   
Other Feelings (please describe)
24. How much do these other feelings trouble you?