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.

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

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

Question 2: Which of these actions have you been engaged in recently?

Frowning, inactivity, moving slowly, withdrawal, talking little, monotonous voice, giving up, moodiness

Withdrawing, hiding, avoiding someone you've hurt, slumped posture, apologizing, giving gifts, trying to fix things

Mean expressions, clenching your teeth, a red face, verbally attacking, physically attacking, cursing, complaining, being aggressive or threatening, stomping, brooding

Fearful talk, shaking, crying, yelling, pleading for help, fleeing, hiding, being speechless, having a frozen stare

Question 3: Which of the following have you noticed recently?

Disoriented, dazed, losing control, remembering threatening times, shock

Focusing on one thing that has caused you to feel upset, ruminating, numbness, depersonalization

Irritable, grouchy, blaming yourself, hopelessness, fainting, nightmares, insomnia, disturbed appetite, numbness

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 5: Have you interpreted any life situations in the following ways recently?

Thinking that you will be separated form something important for a long time; you are worthless and not valuable; you won't get what you need; hopeless beliefs

Your body is too big; you are bad; you are a failure; you are silly and stupid; you are not "good enough", believing that you are a "loser"; believing that you are unlovable

Life is unfair; things should be different; "I'm right"; judging the situation to be unfair

Thinking that someone will reject, criticize, or dislike you; that you won't get the help you need; that you will lose any help you have; losing control; losing competence; believing that you could be hurt, or even die

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

apprehension, anxiety, distress, dread, fright, overwhelmed, panic, worry

agitation, annoyance, envy, frustration, irritation, torment, outrage, resentment

Question 7: Do you identify with any of these words?

Shyness, fragility, bashfulness

Weariness, dissatisfaction, dubiousness, skepticism, doubtfulness, apathy, boredom, dullness

Impatience, hurt, hostile, rage, hateful, critical

Cautiousness, reluctance, suspiciousness, caginess, wariness, confused, insecure

Question 8: What do you think the opposite of your recent experience would be?

Sweet, friendly, tame, wise, patient, calm, successful, pleased, soothed,

Excited, energetic, playful, creative, aware, fascinating, amused, delightful, cheerful

Trusting, loving, intimate, thoughtful, content, relaxed, serene, thankful

Proud, respected, appreciated, hopeful, important, faithful, valuable, worthwhile, intelligent, confident

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

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 done wrong

Stomp, hit, throw, beat-up, hurt someone or something, explode, break things

Question 10: Which of the following emotions do you think you have been dealing with?

Shame

Anger

Sadness

Fear