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Department of Psychology

Jamia Millia Islamia


New Delhi-110025

This questionnaire contains a series of questions on social


Phobia and Anxiety. The test is divided into three parts. Each
part has a different instruction to be followed. Please read the
instructions carefully before answering the questions. This test
will be used only for undergraduate research purposes and the
responses will be kept confidential. Please answer all the
questions honestly. Your participation is appreciated.

Name (optional) - ______________________

Age- _____________

Sex – (M) (F) (others)

Academic Qualifications-
________________________________________________________

In case of any queries regarding the questionnaire, feel free to


contact:
Saima Hasan: +91 9821225945
Shivam Mudgal: +91 97117 97960
PART- 1
This questionnaire assess the way that social phobia plays a role in your life across a variety
of situations. Read each situation carefully and answer two questions about that situation, on
a scale of 0 to 3. The first question asks how anxious or fearful you feel about that situation.
The second question asks how often you avoid that situation. If you come across a situation
that you ordinarily do not experience, we ask that you imagine “what if I was faced with that
situation”, and then rate the degree to which you would fear that hypothetical situation and
how often you would tend to avoid it.

Please base your ratings on the way the situations have affected you in the last week.
Fill out the following scale with the most suitable answer out of the ones provided below:

How much do you fear and avoid the following situations? Please give separate
readings for fear and avoidance.

FEAR AVOIDANCE

0- None 0- Never (0%)

1- Mild 1- Occasionally (1%-33%)

2- Moderate 2- Often (33%-67%)

3- Severe 3- Usually (67%-100%)

S.NO. SITUATIONS FEAR AVOIDANCE


(0-3) (0-3)
1. Telephoning in public.

2. Participating in small groups.

3. Eating in public places.

4. Drinking with others in public places.

5. Talking to people in authority.

6. Acting, performing, or giving a talk in


front of an audience.
7. Going to a party.

8. Working while being observed.

9. Writing while being observed.


10. Calling someone you don’t know very
well.
11. Talking with people you don’t know
very well.
12. Meeting strangers.

13. Urinating in a public bathroom.

14. Entering a room when others are


already seated.
15. Being the centre of attention.

16. Speaking up at a meeting.

17. Taking a test.

18. Expressing a disagreement of


disapproval to people you don’t know
very well.
19. Looking at people you don’t know very
well in the eyes.
20. Giving a report to a group.

21. Trying to pick up someone.

22. Returning goods to a store.

23. Giving a party.

24. Resisting a high pressure salesperson.


PART-2
This questionnaire assesses the way how social phobia plays a role in your daily life
situations. Read each statement carefully and answer the two questions given for each
situation. The first question asks how fearful/anxious you feel about that situation. The
second question asks how often you avoid that situation. Respond to the situations on a scale
of 0-4. If you come across a situation that you ordinarily do not experience, we ask that you
imagine “what if I was faced with that situation” and then rate the degree to which you
would fear that hypothetical situation and how often you would tend to avoid it.

Please base your ratings on the way the situations have affected you in the last week.
Fill out the following scale with the most suitable answer.

Part-2.1
How much do you fear and avoid the following situations? Please give separate
readings for fear and avoidance.

FEAR / ANXIETY AVOIDANCE

0-None 0-Never

1-Mild 1-Rare

2-Moderate 2-Sometimes

3-Severe 3-Frequent

4-Extreme 4-Always

S. SITUATIONS FEAR/ANXIETY AVOIDANCE


No. (0-4) (0-4)
1. Speaking in public or in front of
others.
2. Talking to people in authority.

3. Talking to strangers.
4. Being embarrassed or humiliated.

5. Being criticized.
6. Social gatherings.

7. Doing something while being


watched (this does not include
speaking).
Part-2.2
When you are in a situation that involves contact with other people, or when you are
thinking about such a situation, do you experience the following symptoms?

Fill out the following scale with the most suitable answer.

Scale: 0- None

1- Mild

2- Moderate

3- Severe

4- Extreme

S. SYMPTOMS SCALE
No. (0-4)
8. Blushing

9. Palpitations

10. Trembling

11. Sweating
Part 3
This form contains a number of statements dealing with certain samples of
behaviour and situations that most people experience at one time or another. Please read
each statement carefully and see if it applies to your usual mode of behaving. That is,
you have to decide each statement as a sample of behaviour is true as applied to you or
False as applied to you.
Against each statement you will find ‘T’ and ‘F’ (denoting True and False). If a
statement is TRUE or MOSTLY TRUE as applied to your behaviour, underline ‘T’. If
a statement is False or Mostly False as applied to you, underline ‘F’ against the
appropriate number of the statement.
For example: -
1. I dislike being lonely ………………..……………..……… T F
If the above statement is True or mostly true as applied to your mode of behaving, i.e.
If you do not like being lonely, you underline ‘T’ in the manner done above. In case
you are not bothered by ‘loneliness you should underline ‘F’. Remember, you have to
indicate your own opinion about yourself. In this way you have to respond all the
statements.
ANSWER QUICKLY

Do not leave any statement unanswered

Serial Please
Statement
No. underline
1. I feel uncomfortable on a conveyance which is driven at a T F
fast speed
2. I am often upset even by the slightest noise T F
3. When I meet a member of the opposite sex (Girl or boy, as T F
the case may be), I feel somewhat uneasy.
4 When I go out of my house, I sometimes suspect that I have T F
not looked my door or my trunk.
5. I often feel uneasy that my make fun of me. T F

6. I sometimes suspect that some friends of mine may reveal T F


my secrets.
7. Often I experience a sense of guilt without any cause. T F
8. I sometimes bite my nails. T F

9. I often have the foreboding that some misfortune or bad T F


luck may befall me.
10. I sweat very easily even on cool days. T F
11. I always have bade and fearful; dreams. T F
12. I am sometimes sorry that I may become impotent. T F
13. I am sometimes disturbed by the thought that I may not be T F
able to make good progress in my work.
14. Criticism upsets me greatly. T F
15, Sometimes I get such an intense feeling of shame that I feel T F
like getting faraway from society.
16. I feel uncomfortable if someone talks of my mistakes in the T F
presence of others.
17. I ready drink water outside for fear that it may contain T F
disease germs.
18. Sometimes I feel unhappy without any apparent cause. T F
19. I often feel that I am being ignored by others. T F
20. I am easily embarrassed. T F
21. I often find it hard to concentrate or keep my mind on one T F
job of work.
22. I often feel sick in my stomach. T F
23. My hands trembles or shake when I try to do some work. T F
24. I sometimes fear that I may look awkward in my new dress. T F
25. I often feel disturbed that I am going to blush. T F
26. I often feel my heart beating fast. T F
27. I am little more nervous than others. T F
28. I feel like crying quite easily, T F
29. At time I lose sleep over worry. T F
30. I feel uneasy when I have to meet my superiors (teacher, T F
boss etc.)
31. At times I get very restless. T F
32. Often I ashamed even at the faults of other. T F
33. I am often short of breath when engaged in quick work. T F
34. It is under great deal of strain that I do my work. T F
35. I often feel that I am not wanted at all by any one. T F
36. I tend to tremble or perspire when I face a difficult task T F
ahead.
37. Sometimes I dream That I have been taken ill seriously. T F
38. I often dream about things, I do not like to tell other people. T F

39. If I have to wait for something, I feel uneasy. T F

40. My feeling get hurt quite easily. T F


41. I often worry about something or the other. T F
42. I have great deal of stomach trouble. T F
43. I have good deal of difficulty in coming to a decision. T F

44. I have at times been very worried about things which did T F
not really matter.
45. I often fear that I may lose my friends. T F
46. Sometimes I get so excited that I cannot speak clearly. T F
47. I am more self-conscious than others. T F
48. I often find life to be something of a strain. T F
49. I am not a time at all confident about myself. T F
50. It is at time at times difficult for me to maintain mental T F
balance.
51. When I wake up due to a bad dream, I find it difficult to T F
sleep again.
52. Sometimes I get feelings of shame or remorse even on small T F
matters.
53. I feel nervous when I have to meet a person I have not T F
known before.
54. My sleep is usually restless and disturbed. T F
55. Sometimes I have the feelings that I cannot face the society. T F
56. When two or more people are talking in whispers I often T F
have the feeling that they are talking about me.
57. If I make an awkward social mistake, I find difficult to T F
forget it.
58. I often feel somewhat ashamed when I think of past events T F
of my life.
59. Sometimes I feel disturbed that my children will not respect T F
me when I grow old.
60. I feel a little worried when I have to start on a journey. T F
61. I dislike facing situations where I am required to make T F
quake decision.
62. I often worry that my appearance is not attractive. T F
63. Sometimes feel that I am Aim getting old too soon. T F
64. I feel uneasy when I have to consult a doctor or a surgeon. T F
65. I sometimes suspect that my friends may let me down T F
66. When I do something new, I feel disturbed whether others T F
would approve of it or not.
67. I have often been worried about my health. T F
68. Even when I am in a group I often get the feelings of being T F
lonely.
69. When I am waiting for someone who has promised to come T F
at a particular time I often feel that he may not turn up.
70. Sometimes I feel anxious due to causes I am not clearly T F
aware of.
71. Many a time I have a feeling of being confused. T F
72. Quite often I am unable to decide what course of action is T F
good for me.
73. I am frequently uncertain about myself. T F
74. Sometimes I get the feeling that I am a worthless person. T F
75. I often get the feeling that this world and human existence is T F
meaningless.
76. I seldom can begin any work because of the thought that I T F
may fail in it.
77. I often dream of death of some near and dear ones. T F
78. I get tired very quickly. T F
79. I get sweat in my palm frequently. T F
80. I dislike talking before a group of people for fear that they T F
may mock at what I say.
81. I often have the feeling that some calamity will befall me. T F
82. I sometimes get the feeling that people do not like me. T F
83. I often worry as to what my fate has in store for me. T F
84. I am often blamed for the doings of others. T F
85. I often worry over petty things. T F
86. I often get perturbed at the thought that I may not fulfill my T F
promise.
87. I get over-exited in a difficult situation. T F
88. I feel hungry almost all the time. T F
89. I often worry that I may get involved in some troubles in T F
future.
90. I feel disturbed at the thought that in old age my health may T F
breakdown.
91. The thought that some death or tragedy may befall my T F
family disturbs me.
92. I often feel worried that I may be discharge from my job. T F
93. At times I get so excited that it is hard to get any sleep. T F
94. I feel disturbed at the thought that one day I shall also grow T F
old.
95. I can seldom hide my excitement. T F
96. I tend to stammer when I have to talk to members of the T F
opposite sex.
97. I often wonder if my friends will respect me when I am old. T F
98. I feel disturbed that I may lose my physical capacities in old T F
age.
99. I often worry that in my anger I may one day kill someone T F
or harm him grievously.
100. I often worry as to what will happen to my family after I T F
die.

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