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| Almost Never | Sometimes | Often | Almost Always |
| 1. | I feel pleasant | 1 | 2 | 3 | 4 |
| 2. | I feel nervous and restless | 1 | 2 | 3 | 4 |
| 3. | I feel satisfied with myself | 1 | 2 | 3 | 4 |
| 4. | I wish I could be as happy as others seem to be | 1 | 2 | 3 | 4 |
| 5. | I feel like a failure | 1 | 2 | 3 | 4 |
| 6. | I feel rested | 1 | 2 | 3 | 4 |
| 7. | I am “calm, cool, and collected” | 1 | 2 | 3 | 4 |
| 8. | I feel that difficulties are piling up so that I cannot overcome them | 1 | 2 | 3 | 4 |
| 9. | I worry too much over something that really doesn’t matter | 1 | 2 | 3 | 4 |
| 10. | I am happy | 1 | 2 | 3 | 4 |
| 11. | I have disturbing thoughts | 1 | 2 | 3 | 4 |
| 12. | I lack self-confidence | 1 | 2 | 3 | 4 |
| 13. | I feel secure | 1 | 2 | 3 | 4 |
| 14. | I make decisions easily | 1 | 2 | 3 | 4 |
| 15. | I feel inadequate | 1 | 2 | 3 | 4 |
| 16. | I am content | 1 | 2 | 3 | 4 |
| 17. | Some unimportant thoughts runs through my mind and bothers me | 1 | 2 | 3 | 4 |
| 18. | I take disappointments so keenly that I can’t put them out of my mind | 1 | 2 | 3 | 4 |
| 19. | I am a steady person | 1 | 2 | 3 | 4 |
| 20. | I get in a state of tension or turmoil as I think over my recent concerns and interests | 1 | 2 | 3 | 4 |