Name ____________________________ Date: _______________

Please answer honestly by writing yes or no to the following items

A.
i. I frequently suspect that other people are exploiting, harming, or deceiving
me. _____
ii. I find that thinking about whether or not the people in my life are loyal or
trustworthy dominates in my thoughts. ______
iii. I am reluctant to tell someone about a personal or private matter because
I fear they will use the information to harm me. ______
iv. Other people often say things or do things to demean or threaten
me._____
v. When someone insults, injures, slights me, I find it very hard to forgive. I
usually bear grudges. _______
vi. I find that other people often say or do things to attack my character or
reputation. I counterattack or react angrily to them. ______
vii. When I am involved in a relationship, I repeatedly suspect my partner of
being unfaithful to me. _______
B.
i. I find that I neither desire to be nor enjoy being close to other people,
including my family. ________
ii. When I have a choice, I always choose activities that I can do alone
without other people. _________
iii. It will be okay with me if I lived the rest of my life without a romantic or
sexual experience with other people. ________
iv. I find that very few activities bring me pleasure or enjoyment. _______
v. Other than my immediate family, I find that I do not have close friends, or
people with whom my share personal matters or secret. _______
vi. When other people praise or criticize me, I find that it does not affect me.
_________
vii. I rarely experience strong emotions like anger or joy. I rarely reciprocate
gestures or facial expressions like smiles or nods. ________
C.
i. I often feels as though other people are talking about me or watching me.
_______
ii. Im very superstitious. I preoccupied with paranormal or magical
phenomena. I have special powers to sense events before they happen or
to read the thoughts of other people. ________
iii. Sometimes I have the sense that another person, whom other people
cannot see, is present and speaking with me. _______
 iv. Other people ever tell me that the things me, or the way I say them, are
unusual or even inappropriate. ________
v. I frequently suspect that other people are exploiting, harming, or deceiving
me. _________
vi. I notice that my emotional experiences and expressions stay within a
narrow range and I do not respond to emotionally provocative situations
as they expect. __________
vii. Other people ever respond to me as if my behavior or appearance was
odd or bizarre. _________
viii. Other than my immediate family, I find that I do not have close friends or
people with whom my share personal matters or secret. __________
ix. I am usually worried or anxious in social settings, especially when I am
with unfamiliar people. ___________
D.
i. I have destroyed or stolen the property of other people, harassed other
people, or done other things that I could have gotten me arrested.
_________
ii. I often misrepresent myself by claiming accomplishments, qualities, or
identities that are not my own. I often deceive other people for pleasure or
financial gain. ________
iii. I often struggle to formulate and follow a plan. I often act on the spur of the
moment, without a plan or consideration of the consequences. ________
iv. I am often so grumpy or irritable that I frequently confront or even attack
other people. I have ever attacked someone or been in physical fights that
I did not begin as self-defense. _________
v. I often engage in dangerous, risky, and potentially self-damaging activities
with little thought to the consequences for myself or others. ________
vi. When I enter into agreements or make promises, I often disregard and fail
to follow through on my commitments. When I have familial obligations
and financial debts, I often disregard them. __________
vii. I am rarely concerned about the feelings, needs, or suffering of other
people. I have ever hurt or mistreated someone else, I feel very regret or
remorse after doing so. __________
E.
i. When I sense that someone close to me is going to abandon me, I
undertake emotional or even frantic efforts to keep them from leaving me.
_________
ii. Many of my close friends are intense and unstable. I alternate between
feelings as though the people in my life are really good and really bad.
_________
 iii. I have very unstable or poorly developed sense of who I am. My
aspirations, goals, opinions, and values change suddenly and frequently.
________
iv. I often act on the spur of the moment, without a plan or consideration for
the outcome. I frequently engage in dangerous, risky, and potentially self-
damaging activities without regard to their consequences. ________
v. I sometimes threaten to harm myself or even kill myself. I have thoughts of
attempting to hurt, harm or kill myself. _________
vi. My emotions are easily aroused or intense. I often have intense feelings of
sadness, annoyance, or worry that usually only last a few hours and never
more than a few days. _________
vii. I often feel empty. ________
viii. I often experience intense anger, often much stronger than the event or
circumstance that triggered it, and frequently loss my temper.________
ix. At times of stress, I ever feel like other people are conspiring against me
or that an outside observer of my own mind, thoughts, feelings, and body.
_________

F.

i. I am usually uncomfortable or unappreciated when Im not the center of

attention.________
ii. I flirt with most of the people I met, even though Im not attracted to them.
_________
iii. When I express my emotions or feelings, they change rapidly. Other
people told me that my emotions seem to have little depth or insincere.
_______
iv. I usually dress to impress, spending my time and energy on my clothes
and appearance so I can draw attention to myself. ________
v. Other people tell me that I have strong opinions but that they find it hard to
understand the underlying reasons for my opinions. ________
vi. I am a very expressive or even dramatic person. I have friends or family
repeatedly told me that I embarrassed them with my public displays of
emotion. ________
vii. I frequently change my opinions and feelings based on the people around
me or the people I admire. ________
viii. I often feel close to people early in a relationship and share personal
details of my life. I have been hurt by relationships that I thought were
more serious or intimate than the other person did. ______
G.

i. I describe myself and my accomplishments as so special and unique that

they set me apart my peers. _______
ii. When I imagine the life of my dreams, I think a lot about having unlimited
success, limitless power, unparalleled brilliance, remarkable beauty, or
supreme love. ________
iii. My abilities and needs are special that I feel as though I should associate
only with gifted people or institutions. I feel that only unique or gifted
people are capable of understanding me. ______
iv. I often feel offended if people I respect does not give me the admiration I
deserve. ________
v. I often get annoyed or irritated when people do not follow my wishes or
give the treatment I deserve. _______
vi. Im good at getting people to do what I want. I sometimes take advantage
of people to get the resources or privileges I deserve. ______
vii. I find it hard to recognize or identify with the feelings and needs of other
people. ________
viii. Other people really envy me and my life. I spend a lot of time envying
other people or their lives. _______
ix. Other people ever told me that I acted haughty, patronizing, or arrogant.
_______

H.

i. I often avoid school or work activities that involve a lot of contact with
other people because I fear they will criticize or reject me. ________
ii. I avoid making new friends unless I am certain they like me and accept me
without criticism. _________
iii. In my close relationships, I am usually cautious or restrained because I
fear being shamed or ridiculed. _________
iv. In social situations, I spend a great deal of time worrying that other people
will criticize or reject me. _________
v. In new relationships, I am usually shy, quiet, or inhibited because I fear
that other people will find me inadequate or unsuitable. ________
vi. I perceive myself to be socially inept, personally unappealing, or inferior to
others. ________
vii. I am usually reluctant to take personal risks or engage in any new
activities because I fear will be embarrassed me. _______
I.

i. I struggle to make everyday decisions like what to eat or wear without

advice and reassurance from other people. ______
ii. I prefer to let someone else take responsibility for the major decisions in
my life like where to live, the kind of work I do, and who I befriend. ______
iii. I find it really hard to disagree with the people I count on because I fear
they will disapprove or withdraw their support on me. _______
iv. I often lack self-confidence to start a new project or do things
independently. _______
v. I go to great lengths to receive care and support from other people, even
volunteering to do things I find unpleasant. ______
vi. When Im alone, I often feel uncomfortable or even helpless because I fear
being unable to care myself. _______
vii. After a close relationship ends, I urgently seek another relationship in
which I can receive the care and support I need. _______
viii. I spend a great deal of time worrying about being left alone with no one to
care on me. ________

J.
i. I often find that Im so focused on the details, rules, lists, order,
organization, or schedules for an activity that I lose the essential point of
the activity. _______
ii. I am often unable to complete projects because I cannot meet the high
standards I set for myself. _______
iii. I devote so much time and energy to my work that I have little time of
friendships or recreational activities. I do participate in recreational
activities, I approach them are serious tasks that require organization and
mastery. _______
iv. Other people who share my cultural or religious identification ever tell me
that they find me too strict or too concerned with not doing someone
wrong. I aspire to moral standards that are so high that it is difficult for me
to realize my goals. ______
v. I often find it hard to discard worn-out or worthless objects even when they
have no sentimental value. _______
vi. I find it hard to work other people or delegate tasks because I fear they will
not do things the way I would. _______
vii. I usually find it hard to spend money on myself or other people. I maintain
a standard of living well below what I can afford so I can save money for
catastrophe. _______
viii. I need to be right, or to no change my position, frequently make it difficult
to make and maintain relationships with other people. ______
Name of Spouse: __________________________ Date: _______________
Please answer honestly by writing yes or no to the following items
I.
i. My spouse is exploiting, harming, or deceiving me. _________
ii. My spouse is loyal or trustworthy. ________
iii. My spouse use personal and private information we shared to harm me.
_______
iv. My spouse often say things or do things to demean or threaten me. _____
v. My spouse insults, injures, slights me, he/she finds it very hard to forgive
and he/she usually bear grudges. _________
vi. My spouse often say or do things to attack my character or reputation.
He/she easily gets angry at me. ______
vii. My partner is unfaithful to me. _______

II.
i. My spouse neither desire to be nor enjoy being close to me, including my
family. __________
ii. My spouse choose activities that he can alone or without me.
___________
iii. It is ok for my spouse to live the rest of his life without a romantic or sexual
experience with me. ________
iv. Very few activities bring my spouse pleasure or enjoyment. _______
v. Other than me, my spouse does not have close friends, or people with
whom to share personal matters or secret. _________
vi. When I praise or criticize my spouse, he/she seems not affected.
________
vii. My spouse rarely experience strong emotions like anger or joy. He/she
rarely reciprocate gestures or facial expressions like smiles or nods.
_______

III.

i. My spouse often feels that we are talking about him/her or watching

him/her. _______
ii. My spouse feel she has special powers to sense events before they
happen and they can read the thoughts of other people. ________
iii. Sometimes my spouse have the sense they feel another person, whom
other people cannot see, is present and speaking with me. ________
iv. My spouse ever tell me that the things me, or the way I say him, are
unusual or even inappropriate. _______
 v. My spouse frequently suspects that other people are exploiting, harming,
or deceiving him/her. __________
vi. I notice that my spouses emotional experiences and expressions stay
within a narrow range and he/she does not respond to emotionally
provocative situations as they expect.
vii. My spouse ever respond to me as if my behavior or appearance was odd
or bizarre. ________
viii. Other than my spouses immediate family member, he/she find that he do
not have close friends or people with whom him share personal matters or
secret. __________
ix. My spouse usually worried or anxious in social settings, especially when
with unfamiliar people. _______

IV.
i. My spouse repeatedly destroyed or stolen the property of other people,
harassed other people, or done other things that he could have gotten
arrested. ________
ii. My spouse often misrepresent himself by claiming accomplishments,
qualities, or identities that are not his own. He often deceives other people
for pleasure or financial gain. _______
iii. My spouse often struggle to formulate and follow a plan. He often acts on
the spur of the moment, without a plan or consideration of the
consequences. ______
iv. My spouse often so grumpy or irritable that he frequently confronts or
even attacks other people. He have ever attacked someone or been in
physical fights that he did not begin as self-defense. ______
v. My spouse often engage in dangerous, risky, and potentially self-
damaging activities with little thought to the consequences for himself or
others. _______
vi. When my spouse enter into agreements or make promises, he often
disregard and fail to follow through on his commitments. When he has
familial obligations and financial debts, he often disregards them.
________
vii. My spouse rarely concerned about the feelings, needs, or suffering of
other people. Spouse have ever hurt or mistreated someone else, they
feel very regret or remorse after doing so.______

V.
i. When my spouse sense that someone close to him is going to abandon
him, he undertake emotional or even frantic efforts to keep them from
leaving him. ______
 ii. Most of my spouse close friends intense and unstable. He alternate
between feelings as though the people in his life are really good and really
bad. ______
iii. My spouse has very unstable or poorly developed sense of who he/she is.
My spouse aspirations, goals, opinions, and values change suddenly and
frequently. ________
iv. My spouse often acts on the spur of the moment, without a plan or
consideration for the outcome. My spouse frequently engage in
dangerous, risky, and potentially self-damaging activities without regard to
their consequences. _______
v. My spouse frequently threaten to harm himself/herself or commit suicide.
My spouse have made recurrent attempts to hurt, harm, and kill himself.
_________
vi. My spouses emotions are easily aroused or intense. My spouse often
have intense feelings of sadness, annoyance, or worry that usually only
last a few hours and never more than a few days. _____
vii. My spouse had this chronic of feeling of emptiness that something is
always lacking. _________
viii. My spouse often experience intense anger, often much stronger than the
event or circumstance that triggered it, and frequently loss his/her temper.
______
ix. At times of stress, my spouse ever feels like other people are conspiring
against him or that an outside observer of his/her own mind, thoughts,
feelings, and body. _____

VI.
i. My spouse usually is uncomfortable or unappreciated when he/she is not
the center of attention. ________
ii. My spouse flirts with most of the people he/she meets, even if he/she is
not attracted to them.______
iii. When my spouse express his/her emotions or feelings, he/she change
rapidly. Other people told that his/her emotions seem to have little depth
or insincere. ______
iv. My spouse usually dress to impress spending their time and energy on
their clothes and appearance so he/she can draw attention to others.
________
v. My spouse made strong opinions about others but that he/she find it hard
to understand the underlying reasons for others opinions. _______
vi. My spouse is very expressive or even dramatic person. My spouse has
friends or family repeatedly told that he/she embarrassed them with their
public displays of emotion. ______
 vii. My spouse frequently changes his/her opinions and feelings based on the
people around them or the people he/she admire. ______
viii. My spouse often feel close to people early in a relationship and share
personal details of his/her life. My spouse have been hurt by relationships
that he/she thought was more serious or intimate than the other person
did. _____

VI.
i. My spouse would always describe himself/herself and his/her
accomplishments as so special and unique that they set them apart from
his/her peers. ________
ii. When my spouse imagine he/she think a lot about having unlimited
success, limitless power, unparalleled brilliance, remarkable beauty, or
supreme love. __________
iii. My spouse believes his/her abilities and needs are so special that they
feel as though they should associate only with gifted people or institutions.
He/she feel that only unique or gifted people are capable of understanding
him/her. __________
iv. My spouse often feel offended if people he/she respect do not give the
admiration that he/she deserve. ________
v. My spouse often get annoyed or irritated when people do not follow
his/her wishes or give the treatment he/she wants. _____
vi. My spouse is good at getting people to do what he/she want. My spouse
take advantage of people to get the resources or privileges he/she
wants._______
vii. My spouse finds it hard to recognize or identify with the feelings and
needs of other people. _______
viii. My spouse spends a lot of time envying other people or their lives. ____
ix. My spouse is haughty, patronizing, boastful and/or arrogant. _______

VII.
i. My spouse often avoids school or work activities that involve a lot of
contact with other people because he/she fear they will criticize or reject
him/her. ________
ii. My spouse avoid making new friends unless he/she certain they like and
accept him/her without criticism. ________
iii. In my spouse close relationships, he/she usually cautious or restrained
because he/she fear being shamed or ridiculed. _______
iv. In social situations, my spouse spends a great deal of time worrying that
other people will criticize or reject him/her. ______
 v. In new relationships, my spouse is usually shy, quiet, or inhibited because
he/she fear that other people will find adequate or unsuitable him/her.
_____
vi. My spouse perceives himself/herself to be socially inept, personally
unappealing, or inferior to others. _______
vii. My spouse is usually reluctant to take personal risks or engage in any new
activities because he/she fear will be embarrassed him/her. ______
VIII.
i. My spouse struggles to make everyday decisions like what to eat or wear
without advice and reassurance from other people. ______
ii. My spouse prefers to let someone else take responsibility for the major
decisions in life like where to live, the kind of work he/she do, and who
he/she befriend. ______
iii. My spouse finds it really hard to disagree with the people they count on
because he/she fear will disapprove or withdraw their support on him/her.
____
iv. My spouse usually lacks self-confidence to start a new project or do things
independently. ______
v. My spouse goes to great lengths to receive care and support from other
people, even volunteering to do things he/she find unpleasant. ______
vi. When my spouse is alone, often feel uncomfortable or even helpless
because he/she fear being unable to care himself/herself. ______
vii. After a close relationship ends, my spouse urgently seeks another
relationship in which he/she can receive the care and support he/she
need.______
viii. My spouse spends a great deal of time worrying about being left alone
with no one to care on him/her. _____
IX.
i. My spouse is so focused on the details, rules, lists, order, organization, or
schedules for an activity that lose the essential point of the activity. _____
ii. My spouse often is unable to complete projects because he/she cannot
meet the high standards he/she sets. ______
iii. My spouse devotes so much time and energy for his/her work that he/she
has little time of friendships or recreational activities. He/she does
participate in recreational activities but approach them as serious tasks
that require organization and mastery. ______
iv. My spouse is too strict or too concerned with not doing someone wrong.
He/she aspires to moral standards that are so high that it is difficult for
him/her to realize the goals. _____
v. My spouse often finds it hard to discard worn-out or worthless objects
even when he/she has no sentimental value. _____
vi. My spouse finds it hard to work other people or delegate tasks because
he/she fear will not do things the way he/she would._______
vii. My spouse usually finds it hard to spend money on himself/herself or other
people. He/she maintain a standard of living well below what can afford so
he/she can save money for catastrophe. ______
viii. My spouse has the need to be right or to change his position but
frequently makes it difficult to make and maintain relationships with other
people. _____