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Please enable JavaScript in your browser to complete this form.IAPT Phobia ScaleFull Name *Date of Birth *DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920AddressAddress Line 1CityState / Province / RegionPostal CodeThis service is only available within South Australia. Check our services page for specific locations. Or contact Head to Health directly on 1800 595 212 or visit website www.headtohealth.gov.au for alternative services in their area.Choose a number from the scale that best describes your situation.Social situations due to a fear of being embarrassed or making a fool of myselfChoose a number0 (Would not avoid)12 (Slightly avoid)34 (Definitely avoid)56 (Markedly avoid)78 (Always avoid)Certain situations because of a fear of having a panic attack or other distressing symptoms (i.e. loss of bladder control, vomiting or dizziness)Choose a number0 (Would not avoid)12 (Slightly avoid)34 (Definitely avoid)56 (Markedly avoid)78 (Always avoid)If there is a score above, please elaborate further on the feared consequence:Certain situations because of a fear of a certain object or activity (i.e. animals, heights, blood, confined spaces, driving, flying).Choose a number0 (Would not avoid)12 (Slightly avoid)34 (Definitely avoid)56 (Markedly avoid)78 (Always avoid)If there is a score above, please elaborateDateDD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920EmailSubmit
