Adult Separation Anxiety Questionnaire, ASA-27 Test - the question form
Questions: 27 · 5 minutes
1. You feel safer (more at ease) when you are at home with people close to you.
1 – This happens very often (almost constantly)
2 – This happens quite often
3 – This happens sometimes
4 – This never happens
2. Have you ever found it difficult to leave home even for a few hours?
1 – This happens very often (almost constantly)
2 – This happens fairly often
3 – This happens sometimes
4 – This has never happened
3. Have you ever carried an item with you that made you feel safe or comforted?
1 – This happens very often (constantly)
2 – This happens fairly often
3 – This happens sometimes
4 – This has never happened
4. Have you ever been very anxious before leaving home to go on a long trip?
1 – This happens very often (almost all the time)
2 – This happens quite often
3 – This happens sometimes
4 – This has never happened
5. Do you have nightmares or frightening thoughts about being separated from someone close to you?
1 – This happens very often (almost constantly)
2 – This happens fairly often
3 – This happens sometimes
4 – This has never happened
6. Have you felt very anxious before leaving someone close to you when going away on a trip?
1 – This happens very often (constantly)
2 – This happens fairly often
3 – This happens sometimes
4 – This has never happened
7. Do you get very upset when your usual daily routine is disrupted?
1 – This happens very often (constantly)
2 – This happens fairly often
3 – This happens sometimes
4 – This has never happened
8. Have you worried that your relationships with people close to you were too emotionally dependent (for example, that you became too attached to someone)?
1 – This happens very often (constantly)
2 – This happens fairly often
3 – This happens sometimes
4 – This never happens
9. Have you experienced physical symptoms such as headaches, stomachaches, nausea, or other symptoms when you had to leave home (e.g., before going to school, work, etc.)?
1 – This happens very often (almost all the time)
2 – This happens fairly often
3 – This happens sometimes
4 – This has never happened
10. Do you feel that you talk too much in order to keep people close to you?
1 – This happens very often (constantly)
2 – This happens fairly often
3 – This happens sometimes
4 – This has never happened
11. Have you worried a lot about where your loved ones are when you are not with them (for example, when you go to work or leave the house)?
1 – This happens very often (almost all the time)
2 – This happens fairly often
3 – This happens sometimes
4 – This has never happened
12. Have you found it difficult to fall asleep when you had to stay home alone at night?
1 – This happens very often (almost constantly)
2 – This happens quite often
3 – This happens sometimes
4 – This has never happened
13. Have you noticed that you fall asleep better if you can hear the voices of people close to you, or the sound of the TV, radio, or similar?
1 – This happens very often (almost all the time)
2 – This happens quite often
3 – This happens sometimes
4 – This has never happened
14. Do you get very upset when you think about being separated from people close to you?
1 – This happens very often (constantly)
2 – This happens fairly often
3 – This happens sometimes
4 – This has never happened
15. Do you have nightmares or fantasies about being away from home?
1 – This happens very often (constantly)
2 – This happens quite often
3 – This happens sometimes
4 – This never happens
16. How often do you worry that someone close to you will be in a car accident or develop a life-threatening illness, etc.?
1 – This happens very often (constantly)
2 – This happens fairly often
3 – This happens sometimes
4 – This has never happened
17. Do changes to your usual daily routine upset you a lot if they interfere with seeing people close to you?
1 – This happens very often (constantly)
2 – This happens quite often
3 – This happens sometimes
4 – This has never happened
18. Have you ever felt very worried about family members or loved ones when you were separated from them?
1 – This happens very often (almost constantly)
2 – This happens fairly often
3 – This happens sometimes
4 – This has never happened
19. Do you sleep better if a light is on in the house or in your bedroom?
1 – This happens very often (constantly)
2 – This happens fairly often
3 – This happens sometimes
4 – This has never happened
20. Do you try to be at home alone as rarely as possible, especially when people close to you are not nearby?
1 – This happens very often (constantly)
2 – This happens quite often
3 – This happens sometimes
4 – This has never happened
21. Do you have sudden attacks of anxiety or panic (for example, sudden trembling, sweating, shortness of breath, or a racing heart) when you think that you may have to leave people close to you, or that they may leave you?
This happens very often (constantly)
This happens quite often
This happens sometimes
This has never happened
22. Do you feel more anxious if you do not speak regularly with people close to you by telephone (for example, every day)?
1 – This happens very often (constantly)
2 – This happens quite often
3 – This happens sometimes
4 – This has never happened
23. Do you fear that you would not be able to cope with difficulties if someone who takes care of you were to leave you?
1 – This happens very often (constantly)
2 – This happens fairly often
3 – This happens sometimes
4 – This has never happened
24. Have you had sudden episodes of anxiety or panic (for example, sudden shaking, sweating, shortness of breath, or a racing heart) when you were away from close others?
This happens very often (constantly).
This happens fairly often.
This happens sometimes.
This has never happened.
25. Have you been very worried that certain events (for example, having to travel or work) might separate you from people close to you?
This happens very often (constantly).
This happens quite often.
This happens sometimes.
This has never happened.
26. Have people close to you told you that you talk a lot?
1 – This happens very often (all the time)
2 – This happens fairly often
3 – This happens sometimes
4 – This has never happened
27. Have you ever worried that your relationships with certain people are so close that they could lead to problems?
1 – This happens very often (almost all the time)
2 – This happens fairly often
3 – This happens sometimes
4 – This has never happened