Guidance Sample Questionnaire on Family Impact

Instruction
1. Choose FOUR (4) Senior High School Student in your Barangay. TWO Males and TWO
Females.
2. Let them answer the questions below.
3. Follow the instruction in Rating their answers.

A. Identity
I get anxious and afraid whenever I contemplate doing something new.
I am a people pleaser and am confused about who I am.
I am a rebel. I feel alive when I am in conflict.
I feel there is something wrong with me deep down myself.
I hoard and have trouble letting go of anything.
I feel inadequate as a person.
I am sexually confused.
I feel guilty standing up for myself, I would rather give way to others.
I find it difficult to initiate anything.
I find it difficult to finish things or be consistent to the end.
I constantly think of what others say or think.
I easily criticize myself for being inadequate.
I consider myself a bad person and I easily condemn myself.
I tend to be rigid and perfectionistic.
I feel like always fall short and never get anything right.
I am confused on what I really want.
I feel driven to achieve and succeed in anything.
I believe I really don’t matter except when I am sexual, I am afraid I’ll be rejected
and abandoned if I don’t respond sexually.
I feel empty and depressed very often.
I am confused about who I really am and am unsure about my values or opinions.
TOTAL

B. BASIC NEEDS
I feel out of touch with my physical needs, I don’t know when I am tired, hungry or
sick.
I am resistant to being touched.
I give in sexually even when I don’t really want to.
I had experienced or am having an eating disorder.
I easily feel disturbed by talks or behavior involving sexual activities.
I don’t easily recognize feelings.
I suppress my anger because of shame.
I seldom get angry but when I do, I rage and rant.
I cannot stand angry people and will do anything to keep anger out.
I am shamed when I show some signs of weakness.
I am ashamed when I get frightened.
I avoid as much as possible to express unpleasant emotions.
 I do get obsessed sadistic or masochistic actions.
I am ashamed of my bodily functions.
I suffer from sleep disorders or oversleeping or insomnia.
I enjoy looking pornographic materials.
I have engaged in behavior that may have violated others.
I am sexually attracted to children and I am scared I might act on it.
I believe that I may be addicted to food or sex.
TOTAL

C. SOCIAL
I am basically distrustful of everyone including myself.
I have been or am now emotionally related to an addict.
I am obsessive and controlling in any relationship I am in.
I am addicted to (food, substance, sex, love, gambling).
I isolate myself and avoid people especially authority figures.
I cannot stand being alone and I’ll do almost anything to escape it.
I co-depend by doing what I think others expect of me.
I do everything to avoid conflict.
I feel obligated what others suggest.
I am overly responsible and I am more concerned with another than with myself.
I do not say NO directly but give excuses for not doing what is asked.
I feel incapable of resolving conflicts with others.
I seldom to be clarified when I don’t understand certain things.
I frequently act on my guesses.
I was emotionally distant from both my parents.
I can’t distinguish love from pity. I tend to love people I can pity.
I usually ridicule myself and others if they make a mistake.
I tend to give and conform to the group.
I must always compete and win.
I strongly fear abandonment and I’ll do anything to hold on to a relationship.
TOTAL

HOW to Rate the Answers

I. SUM up all YES Answers TOTAL: _____________
Description:

1–5 = Slightly Wounded

6 – 10 = Moderately Wounded

11 – 15 = Very Wounded

16 – 20 = Severely Wounded

21 + = Extremely Wounded

II. What is your findings from Female Answers?

III. What is your findings from Male Answers?

IV. How do you feel about your discovery?