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You will be presented with a series of problems that people sometimes have. Read each item carefully and indicate your present level of concern about the item. Please answer questions as honestly as possible.
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1. Difficulty concentrating
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No Concern
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5
Most Concerned
2. Discrimination or harassment
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No Concern
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Most Concerned
3. Feelings of failure
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Most Concerned
4. Conflict in relationship
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No Concern
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Most Concerned
5. Feeling left out of things
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No Concern
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Most Concerned
6. Mood swings
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No Concern
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Most Concerned
7. Sexual assault or abuse
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No Concern
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Most Concerned
8. Physical abuse or assault
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9. Lack of life goals or purpose
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No Concern
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Most Concerned
10. Internal conflict or confusion
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No Concern
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11. Pain
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No Concern
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12. Sexual concerns
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No Concern
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Most Concerned
13. Difficulty with children
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No Concern
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Most Concerned
14. Being laughed at or criticized
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No Concern
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15. Financial problems
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No Concern
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Most Concerned
16. Problems sleeping
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No Concern
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17. Feelings of fear or panic
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No Concern
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18. Family conflict
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No Concern
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Most Concerned
19. Unable to forget past mistakes
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No Concern
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Most Concerned
20. Nervous around people
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No Concern
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Most Concerned
21. Nightmares
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No Concern
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Most Concerned
22. Conflict with others
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No Concern
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Most Concerned
23. Feeling hopeless
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No Concern
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Most Concerned
24. Difficulty reaching goals
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No Concern
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Most Concerned
25. Problems at work
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No Concern
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Most Concerned
26. Poor eating habits
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No Concern
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Most Concerned
27. Church attendance
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No Concern
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Most Concerned
28. Health problems
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No Concern
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Most Concerned
29. Having very unusual experiences
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No Concern
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Most Concerned
30. Worried about a family member
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No Concern
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Most Concerned
31. Hear or see things other people don't see or hear
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No Concern
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Most Concerned
32. Death
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No Concern
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Most Concerned
33. Boredom
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No Concern
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Most Concerned
34. Feeling like things are not real
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No Concern
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Most Concerned
35. Distrust of others
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No Concern
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Most Concerned
36. Lack of exercise
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No Concern
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Most Concerned
37. Unhappy too often
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No Concern
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Most Concerned
38. Fear of insanity
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No Concern
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Most Concerned
39. Concern about physical appearance
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No Concern
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Most Concerned
40. Thinking about same thing over and over
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No Concern
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Most Concerned
41. Crying
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No Concern
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Most Concerned
42. Anger
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No Concern
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Most Concerned
43. Recent difficult changes
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No Concern
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Most Concerned
44. Want to die
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No Concern
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Most Concerned
45. Difficulty coping
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No Concern
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Most Concerned
46. Good relationship with God
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No Concern
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Most Concerned
47. Loneliness
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No Concern
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Most Concerned
48. Unloveable
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No Concern
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Most Concerned
49. Memory problems
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No Concern
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Most Concerned
50. Alcohol or drug use
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No Concern
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Most Concerned
51. Need to be perfect
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No Concern
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Most Concerned
52. Stupid people
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No Concern
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Most Concerned
53. Problem with body weight
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No Concern
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Most Concerned
54. Lack of self-control
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No Concern
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Most Concerned
55. Disappointed with yourself
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No Concern
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Most Concerned
56. Feeling like you don't fit-in
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No Concern
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Most Concerned
57. Racing thoughts
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No Concern
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Most Concerned
58. Difficulty speaking up
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No Concern
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Most Concerned
59. No one to talk with
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No Concern
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Most Concerned
60. Others concerned about my drug or alcohol use
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No Concern
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Most Concerned
61. Unable to relax
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No Concern
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Most Concerned
62. Emotional abuse
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No Concern
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Most Concerned
63. Feeling out of control
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No Concern
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Most Concerned
64. Too busy
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No Concern
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Most Concerned
65. Legal problems
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No Concern
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Most Concerned
66. Guilt
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No Concern
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Most Concerned
67. Thoughts of killing or hurting someone
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No Concern
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Most Concerned
68. Fatigue
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No Concern
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Most Concerned
69. Low self-esteem
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No Concern
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Most Concerned
70. Habits interfere with daily activities
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No Concern
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Most Concerned
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