Which physical symptoms have you been experiencing lately?
Choose the closest answer, even if you haven’t experienced all the symptoms.
Sweating, feeling jittery, trembling, shortness of breath, muscle tension, uncomfortable stomach, fe
Stomach pain, having a sense of dread, crying, blushing, wanting to hide, feeling jittery, having a
Frowning, inactivity, moving slowly, withdrawal, talking less than usual, monotone voice, giving up,
Incoherence, tightness in the body, a hot face, muscles tightening, clenched teeth, wanting to hit s
Which of these actions have you been engaged in recently?
Fearful talk, shaking, crying, yelling, pleading for help, fleeing, hiding, being speechless, having
Withdrawing, hiding, avoiding someone you've hurt, slumped posture, apologizing, giving gif
Frowning, inactivity, moving slowly, withdrawal, talking little, monotone voice, giving up, moodines
Mean expressions, clenching your teeth, a red face, verbally attacking, physically attacking, cursin
Which of the following have you noticed about yourself recently?
Irritability, grouchiness, blaming myself, hopelessness, fainting, nightmares, insomnia, disturbed a
Avoiding thoughts, shutting down, blocking emotions, impulsivity, believing I'm defective,
Focusing on one thing that has caused me to feel upset, ruminating, numbness, depersonalizing
Feeling disoriented and/or dazed, losing control, remembering threatening times, shock
Which of these events have happened to you recently, or in the past?
Losing power, status, and respect; being insulted; physical pain; emotional pain; being threatened;
Being in a new place, being alone, being in a place where bad things have happened to me or someone
Doing someone wrong, remembering something wrong that I did, my transgression being "discovered
Things turning out badly, getting what I don't want, not getting what I need or want, the d
Have you interpreted any life situations in the following ways recently?
Thinking I will be separated form something important for a long time; I am worthless and not valuab
Thinking that someone will reject, criticize, or dislike me; that I won't get the help I ne
Life is unfair; things should be different; "I'm right"; judging the situation to
My body is too big; I am bad; I am a failure; I am silly and stupid; I am not "good enough&
Which of the following words would you use to describe how you‘ve been feeling?
Alienation, crushed, disappointment, displeasure, grief, hurt, hopeless, sorrow
Culpability, guilt, embarrassment, humiliation, regret, remorse, mortification
Agitation, annoyance, envy, frustration, irritation, torment, outrage, resentment
Apprehension, anxiety, distress, dread, fright, overwhelmed, panic, worry
Do you identify with any of these words?
Weariness, dissatisfaction, dubiousness, skepticism, doubtfulness, apathy, boredom, dullness
Shyness, fragility, bashfulness
Impatience, hurt, hostile, rage, hateful, critical
Cautiousness, reluctance, suspiciousness, caginess, wariness, confused, insecure
What do you think the opposite of your recent experience would be?
Proud, respected, appreciated, hopeful, important, faithful, valuable, worthwhile, intelligent, conf
Excited, energetic, playful, creative, aware, fascinating, amused, delightful, cheerful
Trusting, loving, intimate, thoughtful, content, relaxed, serene, thankful
Sweet, friendly, tame, wise, patient, calm, successful, pleased, soothed
If you could do anything to express the emotion you are feeling,
without having to suffer the consequences, what would it be?
Run away, change my name, move to a different state, hire a bodyguard
Hide, run away, avoid people, give away money and gifts, try to make up for things I've don
Crawl into a hole and die, kill myself, cry for hours, go to sleep, eat too much or too little
Stomp, hit, throw, beat-up, hurt someone or something, explode, break things
Which of the following emotions do you think you have been dealing with?
Fear
Sadness
Shame
Anger
