2021-2022 Wellness Survey
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Email *
First Name *
Last Name *
What grade are you in? *
Directions: Below is a list of sentences that describe how people feel. Read each phrase and deicide if it is "Not True or Hardly Ever True" or "Somewhat True or Sometimes True" or "Very True or Often True" for you. Then for each sentence, fill in one circle that corresponds to the response that seems to describe you for the last 3 months. *
Not true or hardly ever true.
Somewhat true or sometimes true.
Very true or often true.
When I feel frightened, it is hard to breathe.
I get headaches when I am at school.
I don't like to be with people I don't know well.
I get scared if I sleep away from home.
I worry about other people liking me.
Fill in one circle that corresponds to the response that seems to describe you for the last 3 months. *
Not true or hardly ever true.
Somewhat true or sometimes true.
Very true or often true.
When I get frightened, I feel like passing out.
I am nervous.
I follow my mother or father wherever they go.
People tell me that I look nervous.
I feel nervous with people I don't know well.
Fill in one circle that corresponds to the response that seems to describe you for the last 3 months. *
Not true or hardly ever true.
Somewhat true or sometimes true.
Very true or often true.
I get stomachaches at school.
When I get frightened, I feel like I am going crazy.
I worry about sleeping alone.
I worry about being as good as other kids.
When I get frightened, I feel like things are not real.
Fill in one circle that corresponds to the response that seems to describe you for the last 3 months. *
Not true or hardly ever true.
Somewhat true or sometimes true.
Very true or often true.
I have nightmares about something bad happening to my parents.
I worry about going to school.
When I get frightened, my heart beats fast.
I get shaky.
I have nightmares about something bad happening to me.
Fill in one circle that corresponds to the response that seems to describe you for the last 3 months. *
Not true or hardly ever true.
Somewhat true or sometimes true.
Very true or often true.
I worry about things working out for me.
When I get frightened, I sweat a lot.
I am a worrier.
I get really frightened for no reason at all.
I am afraid to be alone in the house.
Fill in one circle that corresponds to the response that seems to describe you for the last 3 months. *
Not true or hardly ever true.
Somewhat true or sometimes true.
Very true or often true.
It is hard for me to talk with people I don't know well.
When I get frightened, I feel like I am choking.
People tell me that I worry too much.
I don't like to be away from my family.
I am afraid of having anxiety (or panic) attacks.
Fill in one circle that corresponds to the response that seems to describe you for the last 3 months. *
Not true or hardly ever true.
Somewhat true or sometimes true.
Very true or often true.
I worry that something bad might happen to my parents.
I feel shy with people I don't know well.
I worry about what is going to happen in the future.
When I get frightened, I feel like throwing up.
I worry about how well I do things.
I am scared to go to school.
Fill in one circle that corresponds to the response that seems to describe you for the last 3 months. *
Not true or hardly ever true.
Somewhat true or sometimes true.
Very true or often true.
I worry about things that have already happened.
When I get frightened, I feel dizzy.
I feel nervous when I am with other children or adults and I have to do somethings while they watch me (for example, read aloud, speak, play a game, play a sport)
I feel nervous when I am going to parties, dances, or any place where there will be people that I don't know well.
I am shy.
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