Inventory: Self

Please fill out the form and click submit once complete. Rate each statement below: 0=Never, 1=Rarely, 2=Sometimes, 3=Often, 4=Always

Name

First Name

Last Name

1. ___ I experience episodes of a racing heart or breathlessness without exertion or a diagnosed physical illness.

2. ___ I find myself losing my temper over minor matters or snapping at others with little provocation.

3. ___ I lack the energy to do things.

4. ___ I am not interested in eating, or I eat excessively.

5. ___ I am concerned about my sleep habits.

6. ___ I have little to look forward to.

7. ___ I find it difficult to make decisions.

8. ___ I have little or no interest in activities that used to bring me pleasure.

9. ___ I have difficulty being assertive.

10. ___ I am afraid that something bad is going to happen to me.

11. ___ I become angry when I am interrupted.

12. ___ I have feelings of worthlessness or guilt.

13. ___ I find it hard to calm down when I become upset.

14. ___ I feel shaky or nervous over trivial matters – or for no apparent reason.

15. ___ I am told I overreact or blow things out of proportion.

16. ___ I worry about my physical health.

17. ___ I feel like crying but tears never come.

18. ___ I find it difficult to complete tasks.

19. ___ I experience gastrointestinal issues – such as stomachache, nausea or diarrhea – for no known medical reason.

20. ___ I spend money to make myself feel better.