mind garden
SELF-EVALUATION QUESTIONNAIRE STAI Form Y-4
Please provide the following information:
Name Sisiesaseistntse Sesto 7
Age__ Gender (Circle) MF pee
DIRECTIONS: tb,
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esd gach statement and then cre the appropriate number tothe right ofthe statement Sn, Yp % ty,
to indicate how you fet right ow. thats af this moment. There are no right ct wrong o % &G
‘answers, Do not spend too much time on any one statement but give the aswer which & % %% “%
‘seems to dascrbe your present feslings Hest
1. Hee! calm 123 2
2. L feel secure. fae
3. Fam teng€ soe aes i 1 a 8 4
4.1 feel strained: pec ais 123 4
5. { fee! at ease : oe _aruconcen 3 4
a es SHeeen DLsMeMONDEINE eee HUE EEE
7. Lam presently worrying over possible misfortunes... oat 34
8. {Feel satsted.. si ee 12 3 4
9. [feel Irightened d a's @
10. 1 feet comfortable. a a Dace pig es ate
Ls feel selfscon ident eran 23 4
12. | feel nervous 123 4
13. Lam jittery - #23 4
14, [feel indecisive 2