Name:____________________ Gender: ______________

Course/Year:_____________ Age:__________

Please spare a few minutes of your valuable time answer this simple questionnaire.

Below is a list of feelings dealing with general feelings about

yourself. Indicate the amount of your agreement or disagreement

with each item. Please be open and honest in your responses.

Instructions: Put check to the corresponding questions

1. I feel that I’m a person of worth, at least on an equal

plane with others.

Always Sometimes Never

2. I certainly feel useless at times.

Always Sometimes Never

3. All in all, I am inclined to feel that I am a failure.

Always Sometimes Never

4. I am able to do things as well as most other people.

Always Sometimes Never

5. I feel I do not have much to be proud of.

Always Sometimes Never

6. I take a positive attitude toward myself.

Always Sometimes Never

7. At times I think I am no good at all.

Always Sometimes Never