Do you have trouble experiencing deeply connected intimate relationship(s) with someone you feel safe with? *

Never

Seldom

Sometimes

Often

Always

Do you judge others? *

Never

Seldom

Sometimes

Often

Always

Do you think or say negative things about yourself? *

Never

Seldom

Sometimes

Often

Always

Do small things easily frustrate you that others may not get irritated by? *

Never

Seldom

Sometimes

Often

Always

Do you take things personally and frequently get upset by other's actions? *

Never

Seldom

Sometimes

Often

Always

Do you feel dissatisfied with who you are or what you see when you look in the mirror? *

Never

Seldom

Sometimes

Often

Always

Do you routinely do something even if it is bad for you, because your mind or body believes you need it? *

Never

Seldom

Sometimes

Often

Always

Do you hesitate to stand up for yourself when treated unfairly? *

Never

Seldom

Sometimes

Often

Always

Do you put others' needs before your own at the cost of your well-being or happiness? *

Never

Seldom

Sometimes

Often

Always

Do you feel guilty or ashamed? *

Never

Seldom

Sometimes

Often

Always

Is it hard for you to remain composed when criticized? *

Never

Seldom

Sometimes

Often

Always

You need substances or other things to make you feel better when dealing with mental pain, stress, fear or sadness? *

Never

Seldom

Sometimes

Often

Always

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