GENERAL INFORMATION

Name (Optional): Type of Community Living (Rural or Urban):

Family Size: Birth Order (First, Middle, Last, or Only Child):

Parental Presence at Home (Not at all, Sometimes, Always):

MOTIVATION
Statement Strongly Agree Disagree Strongly
Agree disagree
1. I feel that I am a person of worth, at least an equal
with others.
2. I feel that I have a number of good qualities.

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

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

5. I take a positive attitude toward myself.

6. On the whole, I am satisfied with myself.

7. I certainly feel useless at times.

8. At times, I think I am no good at all.

9. I know when I am good with something.

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

Quotient Adversity
Statement Strongly Agree Disagree Strongly
Agree disagree
1. I learn from my mistakes.

2. I feel down if others belittle me.

3. I can’t focus on anything else while worrying.

 4. It is easy for me to be submissive towards others.

5. Im prepared to deal with the consequences of my

actions.
6. I can change my behavior to match the situation.

7. I avoid situation where I could get trouble.

8. I avoid people who could get me into trouble.

9. When my work is criticized, I try harder next time.

10. When im faced with tough situation, I can come up

with new ways to handle it.

Self Reliance
Statement Strongly Agree Disagree Strongly
Agree disagree
1. I know when I am good with something.

2. I can usually achieve what I want if I work hard for it.

3. Im not a big fan of asking others for help.

4. I always form my own opinions with no outside

influence.
5. I always seek out the advice of others, especially
when I have to make a big decision.
6. In my view, I lack strong leadership skills.

7. To boost my self-esteem, I have always sought

approval of my parents or teachers.
8. When I feel ill or tired, I prefer to be left alone rather
than fawned over.
9. If I know ahead of time that I will be highly praised
for doing a good job on a task that makes me work
even harder than I normally would.
10. If I didn’t have my significant other in my life, I would
feel utterly adrift.