Choose a number from the scale below to show how much you would avoid each of the situations or objects listed below. Then write the number in the box opposite the situation.

A17. Social situations due to a fear of being embarrassed or making a fool of myself

A18. Certain situations because of a fear of having a panic attack or other distressing symptoms (such as loss of bladder control, vomiting or dizziness)

A19. Certain situations because of a fear of particular objects or activities (such as animals, heights, seeing blood, being in confined spaces, driving or flying).

People's problems sometimes affect their ability to do certain day-to-day tasks in their lives. To rate your problems look at each section and determine on the scale provided how much your problem impairs your ability to carry out the activity.

1. WORK - if you are retired or choose not to have a job for reasons unrelated to your problem, please tick N/A (not applicable)

2. HOME MANAGEMENT – Cleaning, tidying, shopping, cooking, looking after home/children, paying bills etc

3. SOCIAL LEISURE ACTIVITIES - With other people, e.g. parties, pubs, outings, entertaining etc.

4. PRIVATE LEISURE ACTIVITIES – Done alone, e.g. reading, gardening, sewing, hobbies, walking etc.

5. FAMILY AND RELATIONSHIPS – Form and maintain close relationships with others including the people that I live with