Professional Documents
Culture Documents
Please fill out this page with some details that let us know a little about you.
Gender
Male
Female
City of Residence
Have you ever sought help for emotional or mental health difficulties? If so, please select
the option(s) that best describes the difficulties you experienced:
No, I have never sought help for any emotional or mental health difficulties
Depression
Bipolar Disorder
Bereavement
Anxiety
Substance use disorder
Eating disorder
Psychosis
Would rather not say
Don’t know
Other (please specify)
We would like to ask you some questions about your emotional life, in particular, how
you control (that is, regulate and manage) your emotions. The questions below involve
two distinct aspects of your emotional life. One is your emotional experience, or what
you feel like inside. The other is your emotional expression, or how you show your
emotions in the way you talk, gesture, or behave. Although some of the following
questions may seem similar to one another, they differ in important ways.
For each of the statements presented below, put a check on (5) if you Strongly Agree;
choose number (1) if you Strongly Disagree. Put a check on a number between (1) and (5)
if not in any extreme ends.
1 2 3 4 5
1. When I want to feel more positive emotion (such as joy or
amusement), I change what I’m thinking about.
1 2 3 4 5
22. When I get angry I say things without really knowing why I
am saying them
23. Those close to me often seem to find it difficult to
understand why I do things
41. I’m often curious about the meaning behind others’ actions
42. I have noticed that people often give advice to others that
they actually wish to follow themselves
1 2 3 4 5
11. I often worry that romantic partners don't really love me.
The following questions ask about how you have been feeling during the past 30 days.
For each question, please check the number that best describes how often you had this
feeling. In the past 30 days, how often did you feel...
1 2 3 4 5
2. … nervous?
4. … hopeless?
5. … restless or fidgety?
7. … depressed?
10. … worthless?
This questionnaire contains questions that may relate to your thoughts, feelings,
experiences and preferences. There is no right or wrong answers or trick questions so
please be as honest as possible. For each question please check either "YES" or "NO".
YES NO
1. When in the dark do you often see shapes and forms even
though there is nothing there?
2. Are your thoughts sometimes so strong that you can almost
hear them?
3. Have you ever thought that you had special, almost magical
powers?
4. Have you sometimes sensed an evil presence around you,
even though you could not see it?
5. Do you think that you could learn to read other’s minds if you
wanted to?
6. When you look in the mirror does your face sometimes seem
quite different from usual?
7. Do ideas and insights sometimes come to you so fast that
you cannot express them all?
8. Can some people make you aware of them just by thinking
about you?
15. Are you a person whose mood goes up and down easily?
27. Do you find the bright lights of a city exciting to look at?
32. Have you often felt uncomfortable when your friends touch
you?
36. Do you often feel the impulse to spend money which you
know you can’t afford?
37. Are you usually in an average kind of mood, not too high
and not too low?
38. Do you at times have an urge to do something harmful or
shocking?
39. Do you stop to think things over before doing anything?
43. Do you often feel like doing the opposite of what other
people suggest even though you know they are right?
Thank you!