| RPT |
|Safety Behavior Assessment Form (SBAF)
| Gender: <.Patient_Gender.>
| 33. Check that I can swallow without choking
| <*Answer_8896*>
| 34. Stay within certain distances from home (or other safe places)
| <*Answer_8897*>
| 35. Pay attention to body for physical symptoms or sensations
| <*Answer_8898*>
|
| HEALTH ANXIETY
|
| 36. Call doctors' offices (or health-lines) frequently
|
| <*Answer_8899*>
| 37. Check my body for problems (pain, discomfort, symmetry, discoloration,
| new growth, etc.)
| <*Answer_8900*>
| 38. Research medical symptoms on the internet
| <*Answer_8901*>
| 39. Check my body temperature
| <*Answer_8902*>
| 40. Talk to others about my health or health-related activities
| <*Answer_8903*>
|<*Answer_7771*>
| 41. Request specialized medical exams from providers
| <*Answer_8904*>
|
|Information contained in this note is based on a self-report assessment
|and is not sufficient to use alone for diagnostic purposes. Assessment
|results should be verified for accuracy and used in conjunction with
|other diagnostic activities.
|
| Higher scores suggest more frequent safety behavior usage.
|
|
|Questions and Answers:
|
| VIGILANCE
|
|
| 1. Scope places out before entering
| <*Answer_8864*>
| 2. Sit with back to wall
| <*Answer_8865*>
| 3. Rush through stores or go directly to desired items and leave as
| quickly as possible
| <*Answer_8866*>
| 4. Check yard or the area around your home ("Perimeter Checks")
| <*Answer_8867*>
| Date Given: <.Date_Given.>
| 5. Make up contingency plans in case someone is physically aggressive
| or there is some kind of emergency
| <*Answer_8868*>
| 6. Walk slowly to let someone pass who is close behind
| <*Answer_8869*>
| 7. Watch others for signs of danger
| <*Answer_8870*>
| 8. Check locks on doors or windows
| <*Answer_8871*>
|
| Clinician: <.Staff_Ordered_By.>
| GENERALIZED ANXIETY
|
| 9. Over-plan for everyday events
| <*Answer_8872*>
| 10. Call or contact loved ones to make sure they are ok
| <*Answer_8873*>
| 11. Procrastinate before I start something or make a decision
| <*Answer_8874*>
| 12. Research things before I start or before making a decision
| <*Answer_8875*>
| Location: <.Location.>
| 13. Try to do things perfectly
| <*Answer_8876*>
| 14. Monitor the clock
| <*Answer_8877*>
| 15. Ask others for reassurance (e.g., about a decision or worry)
| <*Answer_8878*>
|
| SOCIAL ANXIETY
|
| 16. Monitor others' reactions to things I say
|
| <*Answer_8879*>
| 17. Prepare things to say while others are talking
| <*Answer_8880*>
| 18. Talk through silences or talk so that silences do not occur
| <*Answer_8881*>
| 19. Be overly polite or agreeable
| <*Answer_8882*>
| 20. Attempt to hide anxiety (e.g., put hands in pocket because they are
| shaking)
| <*Answer_8883*>
| Veteran: <.Patient_Name_Last_First.>
| 21. Leave events or activities early
| <*Answer_8884*>
| 22. Make little eye contact
| <*Answer_8885*>
| 23. Respond to calls with text messages
| <*Answer_8886*>
| 24. Plan and/or rehearse what I am going to say ahead of time
| <*Answer_8887*>
| 25. Make myself look busy while at work or when out in public so that
| others do not talk to me
| SSN: <.Patient_SSN.>
| <*Answer_8888*>
| 26. Cut conversations short
| <*Answer_8889*>
| 27. Monitor what I say in conversations
| <*Answer_8890*>
| 28. Pretend I do not see or recognize someone so that I do not have to
| speak with them
| <*Answer_8891*>
|
| PANIC
| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)
|
| 29. Take it easy when I exercise (or do other activities that require
| physical exertion) so my heart rate does not get too high
| <*Answer_8892*>
| 30. Stay on the outside of crowds and/or monitor for exits or escape routes
| <*Answer_8893*>
| 31. Carry a medication in case I need it
| <*Answer_8894*>
| 32. Check my pulse or heart rate
| <*Answer_8895*>
|
