APPENDICES1

ANXIETY CHECK-LIST NO. 1: ANXIETIES I HAD IN CHILDHOOD

Every child has some worries, fears, or anxieties. Will you please check the following list as to whether you had each worry “never,” “sometimes,” or “often” as a child.

Never Sometimes Often
1. Failing a test in school _____ _____ _____
2. My father losing his job _____ _____ _____
3. Being scolded by the teacher _____ _____ _____
4. Being in an accident _____ _____ _____
5. My mother leaving me _____ _____ _____
6. Not having enough to eat _____ _____ _____
7. Not having girl friends _____ _____ _____
8. Being left behind in my grade at school _____ _____ _____
9. My parents being sick _____ _____ _____
10. Someone following me at night _____ _____ _____
11. My brother or sister leaving me _____ _____ _____
12. Not being popular enough _____ _____ _____
13. Getting struck by a car _____ _____ _____
14. Making a speech before a group in school _____ _____ _____
15. Getting sick _____ _____ _____
16. My father scolding me _____ _____ _____
17. Having bad dreams _____ _____ _____
18. Not having boy friends _____ _____ _____
19. Not being able to get a job _____ _____ _____
20. Dying _____ _____ _____
21. Not being a success _____ _____ _____
22. My brother or sister picking on me _____ _____ _____
23. Having to support my parents some day _____ _____ _____
24. My mother scolding me _____ _____ _____
25. Not getting enough presents at Christmas _____ _____ _____
26. Being in a play in school (stage fright) _____ _____ _____
27. The house burning down _____ _____ _____
28. Being poor _____ _____ _____
29. Being left alone in the dark _____ _____ _____
30. My sister or brother getting more presents than I at Christmas _____ _____ _____
31. My father leaving me _____ _____ _____
32. Whether I would get married _____ _____ _____
33. My father punishing me _____ _____ _____
34. My mother dying _____ _____ _____
35. When my menstrual period came _____ _____ _____
36. Robbers breaking in the house _____ _____ _____
37. Not having an attractive home _____ _____ _____
38. My brother or sister dying _____ _____ _____
39. Being lonely _____ _____ _____
40. Feeling my parents might not care for me _____ _____ _____
41. Witches or ghosts coming _____ _____ _____
42. My mother punishing me _____ _____ _____
43. My father dying _____ _____ _____
44. Not being attractive _____ _____ _____
45. Not being healthy _____ _____ _____
46. Things I saw in movies, like Frankensteins _____ _____ _____
47. Being out in lightning and thunder-storm _____ _____ _____
48. People picking fights with me _____ _____ _____
49. Meeting snakes _____ _____ _____
50. Meeting large animals _____ _____ _____
51. Having the dentist pull a tooth _____ _____ _____
52. Someone ridiculing or making fun of me _____ _____ _____
53. Jumping or falling off a high cliff _____ _____ _____
54. Being shut in a room by myself _____ _____ _____

ANXIETY CHECK-LIST NO. 2: PRESENT ANXIETIES

People worry or have anxiety about different things. Please check this list as to whether you worry or have anxiety about each thing “often,” “sometimes,” or “never.”

1. Being struck by an auto _____ _____ _____
2. Not being attractive to men _____ _____ _____
3. Going to the hospital _____ _____ _____
4. Whether I will be successful at my jobs _____ _____ _____
5. Getting old too soon _____ _____ _____
6. Whether my mother is disappointed in me _____ _____ _____
7. Whether I will be unhappy _____ _____ _____
8. Not having enough money to get along _____ _____ _____
9. Being operated on _____ _____ _____
10. Not having men friends _____ _____ _____
11. Whether my baby will be healthy _____ _____ _____
12. What people in the hospital will say to me _____ _____ _____
13. Being discharged from my work _____ _____ _____
14. What my brother or sister thinks of me _____ _____ _____
15. The city being bombed by enemy planes _____ _____ _____
16. Where I will live _____ _____ _____
17. Nightmares or bad dreams _____ _____ _____
18. Whether I will get married some day _____ _____ _____
19. Being held up by a robber _____ _____ _____
20. What my baby will look like _____ _____ _____
21. Losing my figure _____ _____ _____
22. Not having good health _____ _____ _____
23. What my girl friends think about me _____ _____ _____
24. Dying _____ _____ _____
25. The labor pains of birth _____ _____ _____
26. What my men friends think of me _____ _____ _____
27. Bad luck _____ _____ _____
28. Whether I should keep my baby _____ _____ _____
29. What my father thinks of me _____ _____ _____
30. What kind of work I should follow _____ _____ _____
31. Being lonely _____ _____ _____
32. My father or mother dying _____ _____ _____
33. People being angry at me _____ _____ _____
34. Being poisoned _____ _____ _____
35. Not getting the man I love _____ _____ _____
36. Friends letting me down _____ _____ _____
37. Drowning _____ _____ _____
38. Not getting the approval of the employers I work for _____ _____ _____

ANXIETY CHECK-LIST NO. 3: FUTURE ANXIETIES

People have different worries or anxieties. Please check this list as to whether you worry or have anxiety about each thing “often,” “sometimes,” or “never.”

1. Friends not sticking by me _____ _____ _____
2. Where and how I will live _____ _____ _____
3. Being discharged from my job _____ _____ _____
4. Being hurt in an air raid _____ _____ _____
5. Not having men friends _____ _____ _____
6. What my sister or brother will think of me _____ _____ _____
7. My apartment building catching fire _____ _____ _____
8. How my baby will develop _____ _____ _____
9. Having an operation _____ _____ _____
10. Whether I will get married some day _____ _____ _____
11. Bad dreams or nightmares _____ _____ _____
12. Not getting the man I love _____ _____ _____
13. Being poisoned _____ _____ _____
14. My father or mother dying _____ _____ _____
15. Being lonely _____ _____ _____
16. What kind of work I should follow _____ _____ _____
17. What my men friends will think of me _____ _____ _____
18. Some calamity befalling me _____ _____ _____
19. Not having a good figure _____ _____ _____
20. What my father will think of me _____ _____ _____
21. What future plans I should make for the baby _____ _____ _____
22. Dying _____ _____ _____
23. Not having good health _____ _____ _____
24. What my girl friends say about me _____ _____ _____
25. Being run into by a car _____ _____ _____
26. Getting old too quickly _____ _____ _____
27. Not being successful at my work _____ _____ _____
28. What my neighbors will think of me _____ _____ _____
29. Whether I will be unhappy _____ _____ _____
30. Whether I will have enough money to get along _____ _____ _____
31. How my baby’s health will be _____ _____ _____
32. Not being attractive to men _____ _____ _____
33. Not getting the approval of employers I work for _____ _____ _____
34. People picking fights with me _____ _____ _____
35. A robber entering my house _____ _____ _____
36. What my mother will think of me _____ _____ _____
37. Having teeth pulled by a dentist _____ _____ _____
38. Having to go to the hospital again _____ _____ _____

Note: The above three check-lists are not presented as models for other studies. They were drawn up for the author’s study, and the content of the items is specifically related to that study. They are presented here to enable the reader to see more concretely the basis for one approach to the cases in Chapters 8 and 9.