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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, On Arun osatenens wc pucpishaveunado dacibe hamster cen bon. — psp hy 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

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