1) I rely on the opinion of others to make
decisions.

2) I am very fearful of criticism, disapproval,
or rejection.

3) At times I get so anxious or upset that I
experience most of the following: heart
racing or pounding, sweating; tearfulness;
blushing; difficulty swallowing or lump in
my throat; shaking; poor concentration
dizziness, nausea or diarrhea; butterflies.

4) I often find myself angry or hurt by the
behavior and words of others.

5) I feel too embarrassed to eat out alone or
to attend movies and other activities by
myself.

6) I tend to be a perfectionist, needing to
look perfect and to do things perfectly.

7) I often avoid situations where I think I will
be uncomfortable.

8) I think life is harder for me than for most
other people.

9) I grew up in a dysfunctional home.

10) I am not very aware of my feelings.

11) I am easily discouraged.

12) I do not set goals for the future.

13) I’m fearful that I will say or do something
that will make me look stupid or
incompetent.

14) I’m fearful that I will say or do something
that will make me look stupid or
incompetent.

15) I sometimes lie when I feel that the truth
would result in criticism or rejection.

16) I often refrain from sharing my opinions,
my ideas, and my feelings in groups.

17) I often think that others don’t respect me.

18) I often make decisions on the basis of
what would please others rather than on
what I want or without even considering
what I want.

19) At night, I frequently review my day,
analyzing what I said and did or what
others said and did to me that day.

20) I often feel that others mistreat me and or
take advantage of me.

21) I frequently think negative thoughts
about myself and others.

22) I often compare myself to others.

23) I often feel like I don’t know what is
expected of me.

24) I tend to think that I have higher standards
than others.

25) I felt inferior or inadequate as a child.

26) ’ve been told I’m too sensitive.

27) I try to avoid conflict and confrontation

28) I often procrastinate

29) I often get so anxious that I don’t know
what to say.

30) I’m one of the following: The person who
reveals too much personal information
about myself or the person who

31) I have found it difficult to perform
adequately or without embarrassment
when involved in sex.

32) I tend to think negatively much of the time

33) I tend to let fear and anxiety control many
of my decisions.

34) I have not accomplished what I am
capable of due to fear and avoidance.

35) I often get defensive and strike back when
I perceive I am being criticized.

36) I have avoided making changes in my life
because I was fearful of making a mistake
or failing.

37) I often feel depressed about things I’ve said
and done, or things I failed to say or do.

38) I fear making a mistake which others
might see.

39) I think others are very focused on—and
critical of—what I say and do.

40) I am easily embarrassed.

41) I am very concerned about my
appearance.

42) I often feel like I don’t know the right
thing to do or say

43) I have difficulty knowing who to trust and
when to trust.

44) When someone mistreats me I think that I
must have done something to deserve it.

45) I am anxious and fearful much of the time.

46) I have periods in which I feel devastated
and/or depressed.

47) I am very critical of myself and others

48) I tend to magnify my mistakes and
minimize my successes.

49) I fear being made to look like a fool

50) I generally feel anxious in new social
situations where I may not know what is
expected of me