| YOUR NAME ________ DATE ________ | ||
| For each life area, circle the one answer that you truly feel better describes you. Then move on to the next item, and so on, to the end. If you don’t have any children, write “none” under the word “children” and leave the answer blank. However, make sure you have circled your answer for all other items. | ||
| Life area | Performance (circle one answer for each) | |
| SCHOOL/JOB | Going well | Going worse than I would like |
| FRIENDS | Have enough good friends | I’d like more friends that I can turn to |
| STRANGERS | Comfortable meeting new people | Uncomfortable |
| PARENTS | Proud of me, I think | They underrate me, I think |
| CHILDREN (IF ANY) | I think they’re mostly proud of me | Actually, I think they’re a bit embarrassed |
| FACE | Attractive enough | Needs a lot of work to be presentable |
| HAIR | Satisfied | A worry |
| BODYWEIGHT OR SHAPE | Pretty good for my age group | Bit ashamed |
| HEALTH | Good to excellent | Poor to fair |
| HANDYMAN ABILITY | Passably capable | Pretty useless |
| PHYSICAL FITNESS | Good | Poor |
| SEXUAL PERFORMANCE | Mostly good | A worry to me and I get anxious about it |
| GENDER | Happy with my assigned sex | Misfit and unhappy |