Check off the numbers that you agree with.
- alternative: rate each number from 0 - 5, where 0 = does not apply, 5 = strongly applies, and 1-4 is gradation between.

1. I have difficulty saying “no” when people ask me to do something, even when I know I should not do it.
2. I reel responsible for the problems of others and the world that I did not cause.
3. I have a hard time being good to myself. It feels so selfish!
4. I put others’ needs before my own, even when their needs are not urgent and mine are.
5. When other people give me approval, it helps me to accept myself.
6. When other people criticize something I do, I feel like a failure.
7. I put off doing or saying things which upset people to avoid “making a scene.”
8. In the areas of my life where I experience approval, I often become over-involved.
9. If something I do is not done perfectly, I become impatient.
10. When others point out an imperfection in me, I become defensive.
11. If I am not in control of a situation or project, I feel panicky.
12. I frequently compare myself with other people to see if I’m OK.
13. When I’m around other people who seem to “have it together,” I feel inadequate.
14. Deep down inside, I don’t really like myself, and I hide this from others.
15. When I feel upset, I tend to blame and criticize people and circumstances for my feelings.
16. I have a difficult time getting myself out of unhealthy relationships with others.
17. I sometimes compromise my values to stay in unhealthy relationships with others.
18. I have a difficult time asking people to help me do things I cannot do myself.
19. I often feel burdened with the attitude, “If I don’t do it, then no one else will.”
20. My first reaction to a suggestion to try something new is generally negative.