Answer the following statements with a “no” if you never feel that way – or don’t feel that way any more today.
Answer the following statements with an “yes” if you feel that way today.



1.“I feel as if I will never be acceptable”
2.“I sometimes feel as if I am a fake”
3.“I feel that if people who admire me really knew me, they might have contempt for me”
4.“When I look inside of myself I seldom feel any joy at what I am”
5.“I feel as if God must be disgusted with me”
6.“I feel a lingering sorrow”
7.” I am so tired. I would like to just go to heaven”
8.“I feel I am useless”
9.“I feel I am worthless”
10.“I feel I am valueless”
11.“I feel I am inadequate”
12.“I feel never good enough”
13.“I feel I am no good”
14.“I feel alone, alienated”
15.“I feel abandoned”
16.“I feel I am dirty, damaged”
17.“I feel different, dumb” (” I feel like no one on earth is like me, I wonder if I may have been adopted”)
18.I am defective (flawed)
19.“I have been told that I have poor eye contact, slump my shoulders, or blush easely”
20.“I am more perfectionistic than I would like to be”
21.“I get defensive when others criticize me”
22.“I don’t accept compliments well”
23.“When I make mistakes I feel bad for hours, even days”
24.“I find it difficult to trust that others will meet my needs”
25.“I feel down, helpless and overwhelmed a good deal of time”
26.“I feel hard to rest or relax without feeling guilty”
27.“I was teased and called names when I was young”
28.“If someone does me a favour, I worry about having to return it”
29.“I am sure I have addictive qualities in my personality”
30.“I have difficulty holding a job or maintaining a friendship for a long period of time”
31.“As a child I felt neglected or abused”
32.“I have a hard time to believe that God can fully accept and love me. ”
33.“I never allow myself to get angry ”
34.“My family of origin did not encourage or nurture my self worth”
35.“I have great difficulty getting close to people”
36.“I have secrets that would surprise and shock others”
37.“I feel embarrassed or humiliated ny certain things from the past”
38.“Growing up I received little or no support or praise for my accomplishments”
39.“I have trouble praying to God after I do something wrong.”
40.With my family of Origin, I rarely feel as if I’m treated as an adult.

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