Question 1: Which physical symptoms have you been experiencing lately? Chose the answer that is most like what you have been experiencing, even if you haven't experienced all of the symptoms.
Incoherence, tightness in the body, a hot face, muscles tightening, clenched teeth, feeling the impulse to hit something
Stomach pain, having a sense of dread, crying, blushing, wanting to hide, being jittery, having a sense of suffocation
Frowning, inactivity, moving slowly, withdrawal, talking less than usual, being monotone, giving up, moping
Sweating, having the jitters, trembling, shortness of breath, muscle tension, uncomfortable stomach, feeling cold
Question 2: Which of these actions have you been engaged in recently?
Frowning, inactivity, moving slowly, withdrawal, talking little, monotonous voice, giving up, moodiness
Fearful talk, shaking, crying, yelling, pleading for help, fleeing, hiding, being speechless, having a frozen stare
Mean expressions, clenching your teeth, a red face, verbally attacking, physically attacking, cursing, complaining, being aggressive or threatening, stomping, brooding
Withdrawing, hiding, avoiding someone you've hurt, slumped posture, apologizing, giving gifts, trying to fix things
Question 3: Which of the following have you noticed recently?
Disoriented, dazed, losing control, remembering threatening times, shock
Irritable, grouchy, blaming yourself, hopelessness, fainting, nightmares, insomnia, disturbed appetite, numbness
Focusing on one thing that has caused you to feel upset, ruminating, numbness, depersonalization
Avoiding thoughts, shutting down, blocking emotions, impulsivity, believing you're defective, feeling alienated
Question 4: Which of these events have happened to you recently or in the past?
Being in a new place, being alone, being in a place where bad things have happened to you or someone else
Losing power, status, and respect; being insulted; physical pain; emotional pain; being threatened; having someone enjoyable be interrupted; not getting what you want
Things turning out badly, getting what you don't want, not getting what you need or want, the death of a loved one, loss of any kind, separation from something or someone important to you
Doing someone wrong, remembering something wrong that you did, your transgression being "discovered," a private part of your life is exposed, being teased or criticized, being betrayed, failing, being rejected, having invalidated emotions
Question 6: 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
Question 7: Do you identify with any of these words?
Impatience, hurt, hostile, rage, hateful, critical
Cautiousness, reluctance, suspiciousness, caginess, wariness, confused, insecure
Shyness, fragility, bashfulness
Weariness, dissatisfaction, dubiousness, skepticism, doubtfulness, apathy, boredom, dullness
Question 8: What do you think the opposite of your recent experience would be?
Trusting, loving, intimate, thoughtful, content, relaxed, serene, thankful
Proud, respected, appreciated, hopeful, important, faithful, valuable, worthwhile, intelligent, confident
Excited, energetic, playful, creative, aware, fascinating, amused, delightful, cheerful
Sweet, friendly, tame, wise, patient, calm, successful, pleased, soothed,
Question 9: If you could do anything to express the emotion you are feeling, without having to suffer the consequences, what would it be?
Crawl into a whole and die, kill myself, cry for hours, go to sleep, eat too much or too little
Hide, run away, avoid people, give away money and gifts, try to make up for things I've done wrong
Stomp, hit, throw, beat-up, hurt someone or something, explode, break things
Run away, change my name, move to a different state, hire a bodyguard
