RCADS Child FormDr Emily Carter Child/young person's name First Name Last Name Date of birth of child/young person MM DD YYYY Date completed MM DD YYYY Please put a circle around the word that shows how often each of these things happens to you. There are no right or wrong answers. 1. I worry about things Never Sometimes Often Always 2. I feel sad or empty Never Sometimes Often Always 3. When I have a problem, I get a funny feeling in my stomach Never Sometimes Often Always 4. I worry when I think I have done poorly at something Never Sometimes Often Always 5. I would feel afraid of being on my own at home Never Sometimes Often Always 6. Nothing is much fun anymore Never Sometimes Often Always 7. I feel scared when I have to take a test Never Sometimes Often Always 8. I feel worried when I think someone is angry with me Never Sometimes Often Always 9. I worry about being away from my parent Never Sometimes Often Always 10. I am bothered by bad or silly thoughts or pictures in my mind Never Sometimes Often Always 11. I have trouble sleeping Never Sometimes Often Always 12. I worry that I will do badly at my school work Never Sometimes Often Always 13. I worry that something awful will happen to someone in my family Never Sometimes Often Always 14. I suddenly feel as if I can’t breathe when there is no reason for this Never Sometimes Often Always 15. I have problems with my appetite Never Sometimes Often Always 16. I have to keep checking that I have done things right (like the switch is off, or the door is locked) Never Sometimes Often Always 17. I feel scared if I have to sleep on my own Never Sometimes Often Always 18. I have trouble going to school in the mornings because I feel nervous or afraid Never Sometimes Often Always 19. I have no energy for things Never Sometimes Often Always 20. I worry I might look foolish Never Sometimes Often Always 21. I am tired a lot Never Sometimes Often Always 22. I worry that bad things will happen to me Never Sometimes Often Always 23. I can’t seem to get bad or silly thoughts out of my head Never Sometimes Often Always 24. When I have a problem, my heart beats really fast Never Sometimes Often Always 25. I cannot think clearly Never Sometimes Often Always 26. I suddenly start to tremble or shake when there is no reason for this Never Sometimes Often Always 27. I worry that something bad will happen to me Never Sometimes Often Always 28. When I have a problem, I feel shaky Never Sometimes Often Always 29. I feel worthless Never Sometimes Often Always 30. I worry about making mistakes Never Sometimes Often Always 31. I have to think of special thoughts (like numbers or words) to stop bad things from happening Never Sometimes Often Always 32. I worry what other people think of me Never Sometimes Often Always 33. I am afraid of being in crowded places (like shopping centers, the movies, buses, busy playgrounds) Never Sometimes Often Always 34. All of a sudden I feel really scared for no reason at all Never Sometimes Often Always 35. I worry about what is going to happen Never Sometimes Often Always 36. I suddenly become dizzy or faint when there is no reason for this Never Sometimes Often Always 37. I think about death Never Sometimes Often Always 38. I feel afraid if I have to talk in front of my class Never Sometimes Often Always 39. My heart suddenly starts to beat too quickly for no reason Never Sometimes Often Always 40. I feel like I don’t want to move Never Sometimes Often Always 41. I worry that I will suddenly get a scared feeling when there is nothing to be afraid of Never Sometimes Often Always 42. I have to do some things over and over again (like washing my hands, cleaning or putting things in a certain order) Never Sometimes Often Always 43. I feel afraid that I will make a fool of myself in front of people Never Sometimes Often Always 44. I have to do some things in just the right way to stop bad things from happening Never Sometimes Often Always 45. I worry when I go to bed at night Never Sometimes Often Always 46. I would feel scared if I had to stay away from home overnight Never Sometimes Often Always 47. I feel restless Never Sometimes Often Always Thank you. Your responses have been submitted to your therapist.
