Anxiety making eye contact	Avoidance of eye contact
	0 No anxiety	0 No avoidance
	1 A little anxiety	1 Avoid a little
	2 Moderate anxiety clinic	2 Avoid moderately
	3 A lot of anxiety	3 Avoid a lot
1. Giving a speech	______	______
2. Speaking to a group of people at a party	______	______
3. Speaking up at a meeting	______	______
4. Speaking in a discussion with a few people	______	______
5. Dealing with a cashier when buying something	______	______
6. Being introduced	______	______
7. Greeting an acquaintance passing by on the street	______	______
8. Speaking with someone you don’t know well	______	______
9. Speaking to someone you find attractive	______	______
10. Inviting someone you don’t know well on a date or other social activity	______	______
11. Feeling close to someone you love	______	______
12. Discussing the quality of your work with a boss or a teacher	______	______
13. Having a routine talk with a close family member	______	______
14. Listening while a person speaks to you, in general	______	______
15. Speaking while a person listens to you, in general	______	______
16. Expressing a disagreement	______	______
17. Receiving a compliment	______	______
TOTAL SCORE	______ +	______ =
(Sum of items 1-17):
Grand Total
Descriptive Items
Please rate the additional items on the following scale:
0 — Not at all
1 — A little
2 — Moderately
3 — A lot
18. ____ I avoid eye contact because it make me anxious
19. ____ I avoid eye contact only because it interferes with my concentration (not due to anxiety)
20. ____ I feel self-conscious when I make eye contact.
21. ____ I am concerned that I stare too much into others’ eyes.
22. ____ I have difficulty deciding how much eye contact is best.
23. ____ Making eye contact is important for my social and work relationships
(If you have no anxiety about eye contact, check here ____ and skip items below.)
Complete the following items if you have some anxiety about eye contact or avoidance of eye contact
24. Earliest age when I had anxiety about eye contact or avoidance of eye contact: ____ years old
25. My current anxiety and avoidance related to eye contact is:
0. worse than in my childhood
1. no different than in my childhood
2. a little better than in my childhood
3. moderately better than in my childhood
4. a lot better than in my childhood