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What’s your age?
18-25
26-35
36-45
46-55
56-65
65+
"Most of the time, I feel"
Choose as many or few options as you like
Happy
Sad
Depressed
Anxious
Motivated
Lonely
Indifferent
Other
When in social situations, do you worry that people will notice how anxious you are?
Never
Rarely
Sometimes
Often
Almost always
How often do you imagine others judging you as anxious, weak, crazy, stupid, dull, or straight-up unlikeable when you are in a group setting?
Never
Rarely
Sometimes
Often
All time time
Do you struggle with any of the following?
Choose as many or few options as you like
Receiving criticism
Negative thoughts
Making and keeping eye contact
Replaying situations in your mind
The urge to flee unpleasant situations
Avoiding social gatherings and other interactions
Low self-esteem
Other
Did you face any of the following behavioral or emotional symptoms during the last few months?
Choose as many or few options as you like
Avoiding social interactions with strangers
Going out with friends less frequently
A lack of engagement in the activities you used to enjoy
Feeling worthless or incapable
The fear that your anxiety will be worse than the real situation
Distracting yourself from reality by daydreaming
Feeling rejected, humiliated, or embarrassed
Other
Which aspects of your life do you feel your social anxiety affects most?
Choose as many or few options as you like
Att work
In school
My family
Romantic interests
My relationships with friends
Other
How often is your work, home, and social life or relationships affected by your anxiety?
Never
Rarely
Sometimes
Often
All the time
Thinking about your anxiety – what do you usually do to cope?
Choose as many or few options as you like
I go to therapy
I use alcohol
I use drugs recreationally
I find help in religion
I keep all my feelings inside
I talk to my friends and family
I take medication for my anxiety
Other
Did you face any of the following physical symptoms in social settings during the last few months?
Choose as many or few options as you like
Sweaty hands
Heart racing
Trouble breathing
Trembling hands
Feeling exhausted after social interactions
An upset stomach or bowel problems
Feeling nauseous
A lump in your throat
Your mind going blank
Other
Think about when you experience feelings of anxiety – do any of these situations feature?
Choose as many or few options as you like
Participating in a group activity
Eating or drinking in public
Talking in meetings or classes
Doing your day-to-day job
Using public washrooms
Performing in public
Public speaking
Exercising in public
Meeting people for the first time
Other
Continuing to think about your emotions – which of the following situations do you feel anxious in?
Choose as many or few options as you like
Meeting strangers
Being assertive
Talking with co-workers, friends, etc.
Talking to a person of authority
Dating
Working in a group
Talking to staff in stores, etc
Speaking on the phone
Expressing my opinion
Participating in social events
Other
How often do you experience panic attacks?
Never
Rarely
Sometimes
Often
All the time
Which conditions (if any) have you been diagnosed with in the past?
Choose as many or few options as you like
Anxiety
Depression
ADHD
Elevated stress
Severe fatigue
Other
What caused you to decide to seek help today?
Choose as many or few options as you like
Feeling anxious or panicky
Difficulty in my relationship
A traumatic experience
Trouble sleeping
Issues with abusing drugs or alcohol
Feeling down or depressed
Dealing with stress at work or studies
Other
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