Severity Measure for Separation Anxiety Disorder—Adult Name* Age* Sex: Male Female Date* MM slash DD slash YYYY The following questions ask about thoughts, feelings, and behaviors that you may have had about being separated from home or from people who are important to you. Please rate how often the following statements are true for you. During the past SEVEN (7) DAYS, I have...Input the value that best fits you, (0) Never, (1) Occasionally, (2) Half of the time, (3) Most of the time, (4) All of the time.Felt moments of sudden terror, fear, or fright when separated. (0) Never, (1) Occasionally, (2) Half of the time, (3) Most of the time, (4) All of the time*Please enter a number from 0 to 4.Felt anxious, worried, or nervous about being separated. (0) Never, (1) Occasionally, (2) Half of the time, (3) Most of the time, (4) All of the time*Please enter a number from 0 to 4.Have had thoughts of bad things happening to people important to me or bad things happening to me when separated from them (e.g., getting lost, accidents). (0) Never, (1) Occasionally, (2) Half of the time, (3) Most of the time, (4) All of the time*Please enter a number from 0 to 4.Felt a racing heart, sweaty, trouble breathing, faint, or shaky when separated. (0) Never, (1) Occasionally, (2) Half of the time, (3) Most of the time, (4) All of the time*Please enter a number from 0 to 4.Felt tense muscles, felt on edge or restless, or had trouble relaxing or sleeping when separated. (0) Never, (1) Occasionally, (2) Half of the time, (3) Most of the time, (4) All of the time*Please enter a number from 0 to 4.Avoided going places where I would be separated. (0) Never, (1) Occasionally, (2) Half of the time, (3) Most of the time, (4) All of the time*Please enter a number from 0 to 4.When separated, left places early to go home. (0) Never, (1) Occasionally, (2) Half of the time, (3) Most of the time, (4) All of the time*Please enter a number from 0 to 4.Spent a lot of time preparing for how to deal with separation. (0) Never, (1) Occasionally, (2) Half of the time, (3) Most of the time, (4) All of the time*Please enter a number from 0 to 4.Distracted myself to avoid thinking about being separated. (0) Never, (1) Occasionally, (2) Half of the time, (3) Most of the time, (4) All of the time*Please enter a number from 0 to 4.Needed help to cope with separation (e.g., alcohol or medications, superstitious objects.) (0) Never, (1) Occasionally, (2) Half of the time, (3) Most of the time, (4) All of the time*Please enter a number from 0 to 4.HiddenRaw Score
