Parent Anxiety Rating Form Parent Anxiety Form Name First Last Email Smoking / Vaping 1 - Not concerned 2 - Mildly concerned 3 - Moderately concerned 4 - Highly concerned 5 - Mildly worried 6 - Moderately worried 7 - Highly worried 8 - Mild Panic 9 - Moderately Panic 10 - Panic Attack Refusing medication 1 - Not concerned 2 - Mildly concerned 3 - Moderately concerned 4 - Highly concerned 5 - Mildly worried 6 - Moderately worried 7 - Highly worried 8 - Mild Panic 9 - Moderately Panic 10 - Panic Attack Not sleeping 1 - Not concerned 2 - Mildly concerned 3 - Moderately concerned 4 - Highly concerned 5 - Mildly worried 6 - Moderately worried 7 - Highly worried 8 - Mild Panic 9 - Moderately Panic 10 - Panic Attack Cell phone usage 1 - Not concerned 2 - Mildly concerned 3 - Moderately concerned 4 - Highly concerned 5 - Mildly worried 6 - Moderately worried 7 - Highly worried 8 - Mild Panic 9 - Moderately Panic 10 - Panic Attack Not talking to parents 1 - Not concerned 2 - Mildly concerned 3 - Moderately concerned 4 - Highly concerned 5 - Mildly worried 6 - Moderately worried 7 - Highly worried 8 - Mild Panic 9 - Moderately Panic 10 - Panic Attack Sick / Doesn't feel well 1 - Not concerned 2 - Mildly concerned 3 - Moderately concerned 4 - Highly concerned 5 - Mildly worried 6 - Moderately worried 7 - Highly worried 8 - Mild Panic 9 - Moderately Panic 10 - Panic Attack Doesn't have a job 1 - Not concerned 2 - Mildly concerned 3 - Moderately concerned 4 - Highly concerned 5 - Mildly worried 6 - Moderately worried 7 - Highly worried 8 - Mild Panic 9 - Moderately Panic 10 - Panic Attack Ran out of money 1 - Not concerned 2 - Mildly concerned 3 - Moderately concerned 4 - Highly concerned 5 - Mildly worried 6 - Moderately worried 7 - Highly worried 8 - Mild Panic 9 - Moderately Panic 10 - Panic Attack Drinking Alcohol 1 - Not concerned 2 - Mildly concerned 3 - Moderately concerned 4 - Highly concerned 5 - Mildly worried 6 - Moderately worried 7 - Highly worried 8 - Mild Panic 9 - Moderately Panic 10 - Panic Attack Not exercising 1 - Not concerned 2 - Mildly concerned 3 - Moderately concerned 4 - Highly concerned 5 - Mildly worried 6 - Moderately worried 7 - Highly worried 8 - Mild Panic 9 - Moderately Panic 10 - Panic Attack Bad hygiene 1 - Not concerned 2 - Mildly concerned 3 - Moderately concerned 4 - Highly concerned 5 - Mildly worried 6 - Moderately worried 7 - Highly worried 8 - Mild Panic 9 - Moderately Panic 10 - Panic Attack Isolating / No friends 1 - Not concerned 2 - Mildly concerned 3 - Moderately concerned 4 - Highly concerned 5 - Mildly worried 6 - Moderately worried 7 - Highly worried 8 - Mild Panic 9 - Moderately Panic 10 - Panic Attack Not participating in program 1 - Not concerned 2 - Mildly concerned 3 - Moderately concerned 4 - Highly concerned 5 - Mildly worried 6 - Moderately worried 7 - Highly worried 8 - Mild Panic 9 - Moderately Panic 10 - Panic Attack Δ
