Village Family Clinic & Wellness Center

Available Forms

#1 NEW PATIENT - Mood disorder #2 NEW PATIENT- ADHD assessment #3 NEW PATIENT Health History form #4 NEW PATIENT - PHQ-9 #5 NEW PATIENT Epworth Sleepiness Scale #6 NEW PATIENT CUXOS Anxiety Scale *Binge eating disorder assessment *FOLLOW-UP FORM: Anxiety *FOLLOW-UP FORM: Depression MDQ follow-up Medication renewal form Rejection Sensitivity Dysphoria scale *FOLLOW-UP FORM: ADHD Patient survey

Rejection Sensitivity Dysphoria scale

Name *

1. You ask your parents or another family member for a loan to help you a difficult financial time.

How concerned or anxious would you be over whether or not your family would want to help you? *

(1= very unconcerned, 6= very concerned)

I would expect them to agree to help as much as they can. *

(1= very unlikely, 6= very likely)

2. You approach a close friend to talk to after doing or saying something that seriously upset him/her.

How concerned or anxious would you be over whether or not your friend would want to talk with you? *

(1=very unconcerned, 6= very concerned)

I would expect that he/she would want to talk with me to try to work things out. *

(1= very unlikely, 6= very likely)

3. You bring up an issue with your significant other and tell him/her how important it is to you.

How anxious would you be over his/her reaction? *

(1= very unconcerned, 6=very concerned)

I would expect that he/she would be willing to discuss the issue with me without getting defensive. *

(1=very unlikely, 6=very likely)

4. You ask your supervisor for help with a problem you have been having at work.

How concerned or anxious would you be over whether or not the person would want to help you? *

(1=very unconcerned, 6= very concerned)

I would expect that he/she would want to try to help me out. *

(very unlikely, 6= very likely)

5. After a bitter argument, you call or approach your significant other because you want to make up.

How concerned or anxious would you be over whether or not your significant other would want to make up with you? *

(1= very unconcerned, 6= very concerned)

I would expect that he/she would be as eager to make up as I would be. *

(1= very unlikely, 6=very likely)

6. You ask your parents or other family members to come to an occasion important to you.

How concerned or anxious would you be over whether or not they would want to come? *

(1= very unconcerned, 6= very concerned)

I would expect that they would want to come. *

(1=very unlikely, 6=very likely)

7. At a party, you notice someone on the other side of the room that you'd like to get to know, and you approach him or her to try to start a conversation.

How concerned or anxious would you be over whether or not the other person would want to talk with you? *

(1=very unconcerned, 6=very concerned)

I would expect that he/she would want to talk with me. *

(1=very unlikely, 6=very likely)

8. Lately, you've been noticing some distance between yourself and your significant other, and you ask him/her if there is something wrong.

How concerned or anxious would you be over whether or not he/she still loves you and wants to be with you? *

(1=very unconcerned, 6=very concerned)

I would expect that he/she will show sincere love and commitment to our relationship no matter what else may be going on. *

(1=very unlikely, 6=very likely)

9. You call a friend when there is something on your mind that you feel your really need to talk about.

I would expect that he/she would listen and support me. *

(1=very unlikely, 6=very likely)

How concerned or anxious would you be over whether or not your friend would want to listen? *

(1=very unconcerned, 6=very concerned)

* Required field