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Name*
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Phone Number*
Occupation*
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Would you prefer your consultation ? *
Online
Onsite
1. I feel confident about my abilities. *
1. Not At All
2. A Little Bit
3. Somewhat
4. Very Much
5. Extremely
2. I am worried about whether I am regarded as a success or failure. *
1. Not At All
2. A Little Bit
3. Somewhat
4. Very Much
5. Extremely
3. I feel satisfied with the way my body looks right now. *
1. Not At All
2. A Little Bit
3. Somewhat
4. Very Much
5. Extremely
4. I feel frustrated or rattled about my performance . *
1. Not At All
2. A Little Bit
3. Somewhat
4. Very Much
5. Extremely
5. I feel that I am having trouble understanding things that I read. *
1. Not At All
2. A Little Bit
3. Somewhat
4. Very Much
5. Extremely
6. I feel that others respect and admire me. *
1. Not At All
2. A Little Bit
3. Somewhat
4. Very Much
5. Extremely
7. I am dissatisfied with my weight. *
1. Not At All
2. A Little Bit
3. Somewhat
4. Very Much
5. Extremely
8. I feel self-conscious. *
1. Not At All
2. A Little Bit
3. Somewhat
4. Very Much
5. Extremely
9. I feel as smart as others. *
1. Not At All
2. A Little Bit
3. Somewhat
4. Very Much
5. Extremely
10. I feel displeased with myself. *
1. Not At All
2. A Little Bit
3. Somewhat
4. Very Much
5. Extremely
11. I feel good about myself. *
1. Not At All
2. A Little Bit
3. Somewhat
4. Very Much
5. Extremely
12. I am pleased with my appearance right now. *
1. Not At All
2. A Little Bit
3. Somewhat
4. Very Much
5. Extremely
13. I am worried about what other people think of me. *
1. Not At All
2. A Little Bit
3. Somewhat
4. Very Much
5. Extremely
14. I feel confident that I understand things. *
1. Not At All
2. A Little Bit
3. Somewhat
4. Very Much
5. Extremely
15. I feel inferior to others at this moment. *
1. Not At All
2. A Little Bit
3. Somewhat
4. Very Much
5. Extremely
16. I feel unattractive. *
1. Not At All
2. A Little Bit
3. Somewhat
4. Very Much
5. Extremely
17. I feel concerned about the impression I am making. *
1. Not At All
2. A Little Bit
3. Somewhat
4. Very Much
5. Extremely
18. I feel that I have less scholastic ability right now than others. *
1. Not At All
2. A Little Bit
3. Somewhat
4. Very Much
5. Extremely
19. I feel like I'm not doing well. *
1. Not At All
2. A Little Bit
3. Somewhat
4. Very Much
5. Extremely
20. I am worried about looking foolish. *
1. Not At All
2. A Little Bit
3. Somewhat
4. Very Much
5. Extremely
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