Please answer with R, S or F as the most appropriate
response for each item. Omit any questions that don't
apply to you or that you would prefer not to answer.
Your responses will remain confidential. |
R =
Rarely Applies to Me
S =
Sometimes Applies to Me
F =
Frequently Applies to Me
N =
Not Applicable |
| 1. My current job makes great demands in terms of my performance. |
R
S
F
N
|
| 2. I have problems getting along with members of my family. |
R
S
F
N
|
| 3. I prefer to spend less time with my friends now than I did before. |
R
S
F
N |
| 4. The job I hold has very little career potential for me. |
R
S
F
N |
| 5. The demands made on me by my family are very stressful. |
R
S
F
N |
| 6. Many of the people I meet during the week seem to make me upset. |
R
S
F
N |
| 7. I have difficulty performing my present job to my satisfaction. |
R
S
F
N |
| 8. I have heated arguments with at least one member of my family. |
R
S
F
N |
| 9. Most non-work relationships with other people are very demanding of my time. |
R
S
F
N
|
| 10. Being able to satisfy supervisors is hard to do in my present job. |
R
S
F
N
|
| 11. My living situation is strained and tense. |
R
S
F
N
|
|
12. I have difficulty getting along with those whom I regard as my superiors. |
R
S
F
N |
|
13. The policies followed where I work tend to decrease my job performance. |
R
S
F
N
|
|
14. I wish that I could change my relationship with a member of my family. |
R
S
F
N |
|
15. Because I am so busy, I prefer to keep my social contacts to a minimum. |
R
S
F
N |
|
16. My work requires that I put in a lot of extra time outside regular hours. |
R
S
F
N |
|
17. The type of lifestyle I have interferes with my family activities. |
R
S
F
N
|
|
18. Lately, I have been losing my temper more easily. |
R
S
F
N |
|
19. I have recently taken a new job that demands much more of me than before. |
R
S
F
N |
|
20. I have recently taken on additional family responsibilities. |
R
S
F
N
|
|
21. It would require a lot of effort on my part to make new friends. |
R
S
F
N |
|
22. I should be paid more for the amount and type of work I perform. |
R
S
F
N |
|
23. I wish I could spend more time at home with my family. |
R
S
F
N |
|
24. I have trouble meeting the demands of each day's activities. |
R
S
F
N |
|
25. I am thinking about leaving my present job for better working conditions. |
R
S
F
N |
|
26. I have been thinking about or planning to change my residence. |
R
S
F
N |
|
27. Just being pleasant to friends is getting very hard for me. |
R
S
F
N
|
|
28. My job really leaves me worn out at the end of the day. |
R
S
F
N |
|
29. At present my personal finances are somewhat strained. |
R
S
F
N
|
|
30. I get bored because I have too much leisure time on my hands. |
R
S
F
N |
|
31. After I make a decision, I keep wondering whether it was right or wrong. |
R
S
F
N |
|
32. I don't live up to my own ideals. |
R
S
F
N |
|
33. I am not challenged enough in my job. |
R
S
F
N |
|
34. At work, I have too little voice in decisions that affect me. |
R
S
F
N |
|
35. I don't get enough managerial support in my job. |
R
S
F
N |
|
36. My personal and social life suffer because of my work demands. |
R
S
F
N |
|
37. I get tense at work because I am under pressure. |
R
S
F
N |
|
38. I don't have time to do the things I really value. |
R
S
F
N |
|
39. My family doesn't take my personal needs seriously. |
R
S
F
N |
|
40. At work no one knows if I do a good job or not. |
R
S
F
N |
|
41. My family blames me for mistakes when it is really not my fault. |
R
S
F
N |
|
42. I cannot say "no" to increasing demands from my family. |
R
S
F
N |
|
43. I feel uneasy in competitive situations at work. |
R
S
F
N |
|
44. It is hard for me to ask for help at work. |
R
S
F
N |
|
45. When something gets me angry I hold it in. |
R
S
F
N |
|
46. There is a lot of strain in my interpersonal relationships. |
R
S
F
N |
|
47. The lack of communication at work is frustrating. |
R
S
F
N |
|
48. I have a hard time accepting changes in my work schedule. |
R
S
F
N |
|
49. At times I find it hard to be optimistic. |
R
S
F
N |
|
50. No one listens when I offer solutions to problems at work. |
R
S
F
N |
|
51. One of these days I might tell somebody off at work. |
R
S
F
N |
|
52. When several people ask for things at the same time I get upset. |
R
S
F
N |
|
53. Some days I feel like I can't face my job. |
R
S
F
N |
|
54. I get upset when I think about my family. |
R
S
F
N |
|
55. I think I depend on other people too much. |
R
S
F
N |
|
56. I feel that I am treated unfairly at work. |
R
S
F
N |
|
57. I don't get along with most of the people at work. |
R
S
F
N |
|
58. I get into arguments with my family more often these days. |
R
S
F
N |
|
59. My family life is not satisfying. |
R
S
F
N |
|
60. I don't have a clear understanding of what's expected of me on the job. |
R
S
F
N |
|
61. I don't have time to do the things that are really important to me. |
R
S
F
N |
|
62. It seems like there is just not enough of me to go around. |
R
S
F
N
|
|
63. I don't get to have a quiet time for myself at least once a day. |
R
S
F
N
|
|
64. I feel rushed, pressured or hassled during the day. |
R
S
F
N |
|
65. I feel like I am being pulled in too many directions by the needs of others. |
R
S
F
N |
|
66. I do the things that others expect of me before I do something for me. |
R
S
F
N |
|
67. Whatever I get involved with, it seems like I end with extra responsibility. |
R
S
F
N |
|
68. It is difficult for me to ask for help at work or to delegate work to others. |
R
S
F
N |
|
69. I feel like I might get ill from all the pressure I am under. |
R
S
F
N
|
|
70. I try to be just about perfect in all the activities I am involved in. |
R
S
F
N |
|
71. I feel satisfied with what I can accomplish in a typical day. |
R
S
F
N |
|
72. I feel too tired or irritable to enjoy my life. |
R
S
F
N |
|
73. People take advantage of me and I end up doing more than I should. |
R
S
F
N |
|
74. When I get home from work I can relax, unwind and calm down. |
R
S
F
N |
|
75. I can't set limits on time by saying no to some requests from family or friends. |
R
S
F
N |
|
76. The demands of my life make me feel frustrated and overwhelmed. |
R
S
F
N |
|
77. I believe that I am achieving about as much as I should. |
R
S
F
N |
|
78. I often feel pulled in opposite directions by career and family demands. |
R
S
F
N |
|
79. I have headaches. |
R
S
F
N |
|
80. I can't seem to laugh and have fun anymore. |
R
S
F
N |
|
81. I have backaches or muscle aches in the neck, arms, or shoulders. |
R
S
F
N |
|
82. I feel fatigued or exhausted. |
R
S
F
N |
|
83. I feel sad or blue. |
R
S
F
N |
|
84. I drink more alcohol than I should. |
R
S
F
N |
|
85. I feel used up or burned out. |
R
S
F
N |
|
86. My stress is caused by outside forces beyond my control. |
R
S
F
N |
|
87. I am having sleep difficulties recently. |
R
S
F
N |
|
88. I am trapped by circumstances that I just have to live with. |
R
S
F
N |
|
89. I have been having chest pains (angina) recently. |
R
S
F
N |
|
90. I have been having indigestion, heartburn or upset stomach. |
R
S
F
N |
|
91. I am feeling worried about the future. |
R
S
F
N |
|
92. I am feeling nervous and hyper lately. |
R
S
F
N |
|
93. I have been experiencing dizziness. |
R
S
F
N |
|
94. I have financial obligations that I cannot meet. |
R
S
F
N |
|
95. I feel responsible for the happiness of people around me. |
R
S
F
N |
|
96. I don't know what I want out of life. |
R
S
F
N |
|
97. No matter how much success I have, I feel empty inside. |
R
S
F
N |
|
98. I become resentful when I am hurt, stewing in my anger. |
R
S
F
N |
|
99. I have difficulty accepting criticism from others. |
R
S
F
N |
|
100. I have at least one close friend that I can confide in. |
R
S
F
N |