Do you feel scared to leave your room? Yes/Sometimes/No/Unsure
Do you ever feel ill because of anxiety? Yes/Sometimes/No/Unsure
Do you often wake up in a panic? Yes/Sometimes/No/Unsure
Do you feel safe with people you know? Yes/Sometimes/No/Unsure
Do you prefer to be alone, or with someone you know? Alone/Someone/Unsure (both?)
Do you feel ashamed to be anxious? Yes/Sometimes/No/Unsure
Have you stopped doing activies due to fear? Yes/Some/No/Unsure
Do you fear to use the phone? Yes/Sometimes/No/Unsure
How do you feel about one-on-one therapy? Good/Bad/Unsure
How do you feel about group therapy? Good/Bad/Unsure
How do you feel about the guards patrolling the halls? Good/Bad/Unsure
Do you fear that you are going insane? Yes/Sometimes/No/Unsure
Do you like someone to be there when you panic? Yes/Sometimes/No/Unsure
Do you like to be touched or held when you are having a panic attack? Yes/Sometimes/No/Unsure
Do you often pass out from fear? Yes/Sometimes/No/Unsure
Are you comfortable with your body? Yes/Sometimes/No/Unsure
Do you hate loud noises? Yes/Sometimes/No/Unsure
Do you often wake during the night? Yes/Sometimes/No/Unsure
How often do you have a nightmare? Many times during the night/Every Night/Often/Once in a while/Rarely/Never
Do you find it hard to fall asleep? Yes/Sometimes/No/Unsure
Do you find it hard to fall asleep once woken? Yes/Sometimes/No/Unsure
Do you take naps during the day? Yes/Sometimes/No/Unsure
Do you often fall asleep while sitting up? Yes/Sometimes/No/Unsure
Do you fear to fall asleep? Yes/Sometimes/No/Unsure
Do you feel comfortable with people in the room while you sleep? Yes/Sometimes/No/Unsure
Do you feel comfortable with a single bed, no rails, no restraints? Yes/Sometimes/No/Unsure
Do you wish to have some kind of restraint during the night to stay in bed? Yes/Sometimes/No/Unsure
Do you feel you need sleeping medication? Yes/Sometimes/No/Unsure