Research Survey

What is your gender

• Male
• Female

What is your age?

• 20-25
• 26-30
• 31-35
• 36-40
• 40-45
• 45+

What is your ethnicity?

• American Indian / Alaska Native
• Asian
• Black / African American
• Hispanic or Latino
• White
• Other

What is your relationship status?

• Single
• Dating
• Married
• Divorced
• Widowed

What is your employment status?

• Work full time & student
• Work part time & student
• Full time student
• Part time student

What are your living arrangements?

• Alone
• With parents
• With extended family
• With partner

Is there a history of any of the following in your family, including yourself? (select all that apply).

Please select all that apply.

• Depression
• Anxiety
• Post-traumatic Stress Disorder
• Schizophrenia
• Eating Disorder
• Other Personality Disorder
• None

How often were you bullied growing up?

• Never
• Rarely
• Sometimes
• Often
• Always

Do you worry that you will do or say something that will embarass you infront of other people?

• Never
• Rarely
• Sometimes
• Often
• Always

Do you worry about making a mistake infront of people?

• Never
• Rarely
• Sometimes
• Often
• Always

Do you constantly feel you are being watched and judged by other people?

• Never
• Rarely
• Sometimes
• Often
• Always

Does your fear of embarassment or humiliation keep you from doing things you really want to do?

• Never
• Rarely
• Sometimes
• Often
• Always

Does your fear of embarassment keep you from speaking to people?

• Never
• Rarely
• Sometimes
• Often
• Always

When you have to go to a social situation or event, do you worry about it for days or even weeks ahead of time?

• Never
• Rarely
• Sometimes
• Often
• Always

Do you fear meeting new people or being in situations where you don't know people well?

• Never
• Rarely
• Sometimes
• Often
• Always

Before or during any kind of social situation, do you experience any physical symptoms such as nausea, trembling, blushing or sweating?

• Never
• Rarely
• Sometimes
• Often
• Always

Have you ever experienced panic before or during a social situation because you were constantly thinking about the situation?

• Never
• Rarely
• Sometimes
• Often
• Always

Do you try to avoid social situations?

• Never
• Rarely
• Sometimes
• Often
• Always

Do you sometimes drink to make social situations easier to handle?

• Never
• Rarely
• Sometimes
• Often
• Always

Has your thorughts about certain social situations interfered with your functioning at work or school?

• Never
• Rarely
• Sometimes
• Often
• Always

Has your feelings about certain social situations kept you from having friendships, relationships or any kind of social life?

• Never
• Rarely
• Sometimes
• Often
• Always