Name: Sex:

Grade Level: Age:

Strand:
Instruction: Please read each item carefully and answer honestly on
every item give. Give each item a rating by putting a check (✓) mark
according to the following scales that describes:
4- ALWAYS, 3-OFTEN, 2-SOMETIMES, 1-NEVER. Do not leave any
item unanswered.
SCHOOL
4 3 2 1
1. You cannot pay attention in class.
2. You are studying but still having trouble in
passing tests/assignments.
3. You cannot understand what teacher says.
4. You are not sure if you are able to do well in
school.
5. Your attendance is poor.
6. You are often late in class.
7. You are having too many assignments.
8. You cannot stay awake in class.
9. Others(explain):
Money
1. You cannot get money to pay in school.
2. You feel pressured because it costs a lot of
money to come for school.
3. Your parents control how much money to
spend.
4. You’re having a trouble managing the budget.
5. You cannot get a job.
6. You’re financially responsible for some else.
7. Other’s (explain):
Family
1. You don’t have enough time for your family.
2. You’re not in good terms with your parents.
3. Your parents have higher expectations.
4. You cannot share your problems with them.
5. You will have less contact with them.
6. Others (explain):
Relationship
1. You are having trouble of getting along with
family members.
2. You’re having no friends.
3. You are having a trouble in meeting a
boyfriend/girlfriend.
4. You are fighting with your partner.
5. You are with your parents.
6. You find it hard to express your feelings.
7. You are lonely or missing your
family/friends/partner.
8. Others (explain):
Body, Mind and Feelings
1. You gained too much weight.
2. You lose too much weight.
3. You are tired and sleeping less than normal.
4. You feel sad and depressed all the time.
5. You do not feel like anyone cares.
6. You do not do things that you used to like to do.
7. You feels like that there is too much pressure.
8. You are feeling insecure because of too much
competition in getting good grades.
9. Others (explain):