1. I feel powerless or helpless
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
2. Often I feel like a victim of outside circumstances
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
3. I don't have the money to do what I really want
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
4. There is seldom enough time to do what I want
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
5. Life is very difficult - it's a struggle
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
6. If things are going well, watch out!
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
7. I feel unworthy. I feel that I'm not good enough
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
8. Often I feel that I don't deserve to be successful or happy.
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
9. Often I feel a sense of defeat and resignation: "Why bother!"
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
10. My condition seems hopeless
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
11. There is something fundamentally wrong with me
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
12. I feel ashamed of condition.
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
13. If I take risks to get better, I'm afraid I'll fail
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
14. If I take risks to get better, I'm afraid I'll succeed
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
15. If I recover fully, i might have to deal with realities I'd rather not face.
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
16. I feel like I'm nothing (or can't make it) unless I'm loved
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
17. I can't stand being seperated from others
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
18. If a person I love doesn't love me in return, I feel like it's my fault
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
19. It's very hard to be alone.
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
20. What others think of me is very important
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
21. I feel personally threatened when criticised
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
22. It's important to please others.
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
23. People won't like me if they see who I really am.
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
24. I need to keep up a front or others will see my weaknesses
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
25. I have to achieve or produce something significant in order to feel ok about myself.
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
26. My accomplishments at work/school are extreamly important.
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
27. Success is everything.
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
28. I have to be the best at what I do.
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
29. I have to be somebody - somebody outstanding
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
30. To fail is terrible
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
31. I can't rely on others for help
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
32. I can't recieve from others
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
33. If I let someone get to close, I'm afraid of being controlled
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
34. I can't tolerate being out of control
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
35. I'm the only one who can solve my problems
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
36. I should always be very generous and unselfish.
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
37. I should be the perfect (answer all a-h below)
a. employee
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
b. professional
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
c. spouse
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
d. parent
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
e. lover
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
f. friend
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
g. student
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
h. son/daughter
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
38. I should be able to endure any hardship
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
39. I should be able to find a quick solution to every problem
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
40. I should never be tired or fatigued
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
41. I should always be efficient
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
42. I should always be competent
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
43. I should always be able to foresee everything
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
44. I should never be angry or irritable. Or I don't like (or am afraid of) anger.
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
45. I should always be pleasant or nice no matter how I feel
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly

46. I often feel... (answer all below)
a. ugly
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
b. inferior or defective
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
c. unintelligent
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
d. guilty or ashamed
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
47. I'm just the way I am - I can't really change
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
48. The world outside is a dangerous place
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
49. Unless you worry about a problem it justs gets worse
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
50. It's risky to trust people
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
51. My problems will go away on their own with time
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
52. I feel anxious about making mistakes
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
53. I demand perfection of myself
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
54. If I don't have my safe person (or safe place), I'm afraid I couldn't cope
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
55. If I stop worrying, I'm afraid something bad will happen.
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly

56. I'm afraid to face the world out there on my own

Not at all Sometimes/Somewhat Strongly/frequently Very Strongly
57. My self-worth isn't a given - it has to be earned
Not at all Sometimes/Somewhat Strongly/frequently Very Strongly