Name:_______________________________Age:_____Sex:_____Marital Status:________Date:____________
Rate each of the following statements based on your own experiences. Rate them on the following basis:
1 = never, 2 = seldom, 3 = sometimes, 4 = often.
1 2 3 4 1. In the past, I've had "mixed emotions" about things I planned to do.
1 2 3 4 2. There have been times when the closer I got to something I wanted to do, the more afraid or anxious I got.
1 2 3 4 3. I have had thoughts I wouldn't want to tell others about.
1 2 3 4 4. I have felt confused by my own behavior.
1 2 3 4 5. People I love have told me I gave them "mixed messages".
1 2 3 4 6. I have felt like one part of me wanted to do one thing while another part wanted to do something else.
1 2 3 4 7. I have felt like I both loved and hated the same person.
1 2 3 4 8. I've said to myself, "I hate myself when I do that".
1 2 3 4 9. I've been able to relate to Paul the Apostle's words, "I do the very thing I don't want to do".
1 2 3 4 10. I have had conflicts within myself.
1 2 3 4 11. I find that I talk to myself inside my head.
1 2 3 4 12. I have said something like, "I tell myself I need to (start or stop something) but I just don't do it".
1 2 3 4 13. In a particular situation or relationship I've felt like I knew what to do but then I didn't do it.
1 2 3 4 14. I have done things in the past that I didn't think I would do.
1 2 3 4 15. I have said, "On the one hand I ..., but on the other hand I ..."
1 2 3 4 16. I have done things I wouldn't want to tell others about.
1 2 3 4 17. I criticize myself.
1 2 3 4 18. It seems like there are different parts, sides or aspects of myself.
1 2 3 4 19. I have felt out of control of myself in the past.
1 2 3 4 20. I have said, "I know what I need to do but I just don't do it."
1 2 3 4 21. I have denied myself things that I wanted.
1 2 3 4 22. I have really desired something then been upset with myself when I went ahead and got it.
1 2 3 4 23. I pushed myself beyond what I thought what was good for me in the past.
1 2 3 4 24. There have been times when my own thoughts have surprised me.
c 1996 Stan Eastin
