RCADS47 Caregiver Form

This 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.

Please put a circle around the word that shows how often each of these things happens for your child.

NeverSometimesOftenAlways
My child worries about things
Never
Sometimes
Often
Always
My child feels sad or empty
Never
Sometimes
Often
Always
When my child has a problem, he/she gets a funny feeling in his/her stomach
Never
Sometimes
Often
Always
My child worries when he/she thinks he/she has done poorly at something
Never
Sometimes
Often
Always
My child feels afraid of being alone at home
Never
Sometimes
Often
Always
Nothing is much fun for my child anymore
Never
Sometimes
Often
Always
My child feels scared when taking a test
Never
Sometimes
Often
Always
My child worries when he/she thinks someone is angry with him/her
Never
Sometimes
Often
Always
My child worries about being away from me
Never
Sometimes
Often
Always
My child is bothered by bad or silly thoughts or pictures in his/her mind
Never
Sometimes
Often
Always
My child has trouble sleeping
Never
Sometimes
Often
Always
My child worries about doing badly at school work
Never
Sometimes
Often
Always
My child worries that something awful will happen to someone in the family
Never
Sometimes
Often
Always
My child suddenly feels as if he/she can't breathe when there is no reason for this.
Never
Sometimes
Often
Always
My child has problems with his/her appetite
Never
Sometimes
Often
Always
My child has to keep checking that he/she has done things right (like the switch is off, or the door is locked)
Never
Sometimes
Often
Always
My child feels scared to sleep on his/her own
Never
Sometimes
Often
Always
My child has trouble going to school in the mornings because of feeling nervous or afraid.
Never
Sometimes
Often
Always
My child has no energy for things
Never
Sometimes
Often
Always
My child worries about looking foolish
Never
Sometimes
Often
Always
My child is tired a lot
Never
Sometimes
Often
Always
My child worries that bad things will happen to him/her
Never
Sometimes
Often
Always
My child can't seem to get bad or silly thoughts out of his/her head.
Never
Sometimes
Often
Always
When my child has a problem, his/her heart beats really fast
Never
Sometimes
Often
Always
My child cannot think clearly
Never
Sometimes
Often
Always
My child suddenly starts to tremble or shake when there is no reason for this
Never
Sometimes
Often
Always
My child worries that something bad will happen to him/her
Never
Sometimes
Often
Always
When my child has a problem, he/she feels shaky
Never
Sometimes
Often
Always
My child feels worthless
Never
Sometimes
Often
Always
My child worries about making mistakes
Never
Sometimes
Often
Always
My child has to think of special thoughts (like numbers or words) to stop bad things from happening
Never
Sometimes
Often
Always
My child worries what other people think of him/her
Never
Sometimes
Often
Always
My child is afraid of being in crowded places (like shopping centers, the movies, buses, busy playgrounds)
Never
Sometimes
Often
Always
All of a sudden my child will feel really scared for no reason at all
Never
Sometimes
Often
Always
My child worries about what is going to happen
Never
Sometimes
Often
Always
My child suddenly becomes dizzy or faint when there is no reason for this
Never
Sometimes
Often
Always
My child thinks about death
Never
Sometimes
Often
Always
My child feels afraid if he/she has to talk in front of the class
Never
Sometimes
Often
Always
My child’s heart suddenly starts to beat too quickly for no reason
Never
Sometimes
Often
Always
My child feels like he/she doesn’t want to move
Never
Sometimes
Often
Always
My child worries that he/she will suddenly get a scared feeling when there is nothing to be afraid of
Never
Sometimes
Often
Always
My child has to do some things over and over again (like washing hands, cleaning, or putting things in a certain order)
Never
Sometimes
Often
Always
My child feels afraid that he/she will make a fool of him/herself in front of people
Never
Sometimes
Often
Always
My child has to do some things in just the right way to stop bad things from happening
Never
Sometimes
Often
Always
My child worries when in bed at night
Never
Sometimes
Often
Always
My child would feel scared if he/she had to stay away from home overnight
Never
Sometimes
Often
Always
My child feels restless
Never
Sometimes
Often
Always