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Palo Alto, Califurnia

SELF-EVALUATIONQUESTIONNAIRE STAIForm Y-1

Please provide the following information:

Name Date

Age Gender (Circle) M

O Copyright1968,1977 Press,Inc. All rightsreserved..

by ConsultingPsychologists STAIP-ADTest FormY
 SELF-EVALUATION
QUESTIONNAIRE
STAI Form Y-2

Name Date

DrREcrfoNs \r"^
U ,, Orb
A numberof slalementswhichpeoplehaveusedto describethemselves are givenbelow. %*,'%
Readeachstatementandthencirclethe appropriate numberto the rightof the statementto
"+, 9^ A * ^
indicatehowyou genenlly feel.fhete are no rightor wronganswers.Donotspendtoo Ab^,4o "4,.'br^
'b
muchtimeon anyone statementbutgivethe answerwhichseemsto describehowyou til oO ?
generallyfeel.
21.lfeelpleasant..........................

2 2 . I f e e l n e r v o u S a n d r e S t l e S S . . . . . . . : . . . . . . . 4

23.I feel satisfiedwith myself... 4

2 4 . I w i s h I c o u l db e a sh u p p ya so t h e r ss e e mt o b e . . . . . . . j . . . . . . . . . . . . . . .:..............

25. |feel like a failure 2 3 4

26. Ifeel rested............ 2 3 4

27. I am "calm,cool,andcollected" ................

I
i

28. I feel thatdifficultiesare piiing up so thatI cannotovercomethem:........................:..........

1 2 3 4

29. I worry too much over somethingthat really doesn'tmatter.... .........1 2 3 4

3 0 . I a mh a p p y . . . . . . . . . : . . . . . . . . . . . . . . .I . , 2 3 4

31. I havedisturbingthoughts.......... ..... I 2 3 4

3 2 . I l a c ks e l f - c o n f i d e n c e . , . . . . . . . . . . . . . . . . . .1. 2 3 4

3 3 . I f e e ls e c u r e . . . . . . . . . . . .....:.. . . . . . . . . . . .I. . . 2 3 4

3 4 . I m a k ed e c i s i o n es a s i l v . . . . . . . . . . . . . . . . .I. . 2 3 4

35. I feel inadequate ..........

.... 2 3 4

36. I amcontent........... . . . . . . . . . . .I . . 2 3 4

37. Someunimportantthoughtrunsthroughmy mind and bothersme.. ........ ..... I

,, 3 4

so keenlythat I can't put them out of my mind

38. I take disappointments ...,.....I 2 3 4

3 9 . I a r n as t e a d yp e r s o n . . . . . . . . . . . . . . . . .I. . . 2 3 4

40. I get in a stateof tensionor turmoil as I think over my recentconcernsand interests.........1 z 3 4

@Copyright1968,1977
by ConsultingPsychologists
Press,Inc. All rightsreserved. STAIP-ADTestFormY
 Mrxo GnRnBN
palo AIto, Cdilofilq

State-TraitAnxietyInventoryforAdults ScoringKey (FormY-1,Y-21

Developed by Charles D. Spielberger in collaboration
withR.L.Gorsuch,R. Lushene,P.R.Vagg,and G.A.Jacobs

To usethisstencil,fold thissheetin halfand lineup withthe appropriate

testside,eitherFormY-1 or FormY-2.
Simplytotalthe scoringweights shownon thestencilfor eachresponsecategory.Forexample,for question# 1,
if the respondent
marked3, thenthe weight wouldbe 2. Referto the manualfor appropriate normetivedata.

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\J4

u7,%'%,^
'4r0,
A
o*o
ob oo V'
-\'q'"4'k+'
1t, ty" '% '%
Form Y-1 FormY-2
1. 4 3 2 1 21. 4 3 2 1

2. 4 3 2 1 22. 1 2 3 4

3. 1 2 3 4 23. 4 3 2 1

4. 1 2 3 4 24. 1 2 3 4

5. 4 3 2 1 25, 1 2 3 4

6. r 2 3 4 26. 4 3 2 1

7. r 2 3 4 27. 4 3 2 1

8. 4 3 2 1 28. 1 2 3 4

9. 1 2 3 4 29. 1 2 3 4

10. 4 3 2 1 30. 4 3 2 1

11. 4 3 2 1 31, 1 2 3 4

12. r 2 3 4 32. , 1 2 3 4

13. 1 2 3 4 33. 4 3 2 1

14. 1 2 3 4 34. 4 3 2 1

15. 4 3 2 1 35. 1 2 3 4

16. 4 3 2 1 36. 4 3 2 1

t7. 1 2 3 4 3 1. 1 2 3 4

18. r 2 3 4 38. 1 2 3 4

t9. 4 3 2 1 39. 4 3 2 1

20. 4 3 2 1 40. 1 2 3 4

Distributed by MTNoGRRoeNP.O. Box 60669 PaloAlto California 94300 (415) 424-8493

1983by Consulting
O Copyright Press,Inc. All rightsreserved.
Psychologists STAIP-ADScoringKey