Shivani Gupta - Self Esteem Questionnaire

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self esteem questionnaire

We believe at passionate people that if women of all ages believed in themselves and had a higher sense of self esteem, their lives would be improved considerably and they could lead a life of magnificence.

Your privacy is secured and no last names will be used. Those who complete the survey will go into the draw to win 1 of 10 packs of our book passion@work and the relaxation CD Meditation for Busy People worth over $60 for FREE.

We would also appreciate it if you could send the survey onto other women so we can create products that help women change their lives for the better.

Please tell us your first name:
Optionally, please enter your email address:
1. What age group do you fit in?:	<18 18-24 25-44 45-60 >60
2. What is your relationship status?:	Single Divorced or separated Married De facto Other
3. What would you say is your overall self esteem?:	Low Medium High
4. What is an area that is medium-high on your self esteem?:	Mental (determination, setting goals) Emotional (ability to express oneself) Social (ability to talk to different people) Physical (body image) Physical (health)
5. What is an area that is low-medium on your self esteem?:	Mental (determination, setting goals) Emotional (ability to express oneself) Social (ability to talk to different people) Physical (body image) Physical (health)
6. Do you focus on your positive qualities?:	Always Often Sometimes Very rarely
7. Do you spend a lot of time on, or thinking about your body image?:	Always Often Sometimes Very rarely
8. Do you accept compliments easily?:	Strongly agree Somewhat agree Somewhat disagree Strongly disagree
9. Do you seem to focus only on your flaws when you look in a mirror?:	Always Often Sometimes Very rarely
10. I wish that I could have more self respect.:	Strongly agree Somewhat agree Somewhat disagree Strongly disagree
11. I accept that I make mistakes.:	Strongly agree Somewhat agree Somewhat disagree Strongly disagree
12. Do you think other people's opinions of you are important?:	Always Often Sometimes Very rarely
13. Do you feel that you have control over your happiness?:	Always Often Sometimes Very rarely
14. Do you compare yourself to other women?:	Always Often Sometimes Very rarely
15. Do you feel responsible for failures in your relationships?:	Always Often Sometimes Very rarely N/A
16. Do you tend to blame yourself when things go wrong?:	Always Often Sometimes Very rarely
17. Do you ever look in the mirror and say "I love you" to yourself?:	Always Often Sometimes Very rarely
18. I apologise often.:	Strongly agree Somewhat agree Somewhat disagree Strongly disagree
19. I spend more time wishing than taking action?:	Strongly agree Somewhat agree Somewhat disagree Strongly disagree
20. I live for myself before others.:	Strongly agree Somewhat agree Somewhat disagree Strongly disagree
21. I often wonder what my partner sees in me.:	Strongly agree Somewhat agree Somewhat disagree Strongly disagree N/A
22. I feel great emotionally when having sex.:	Strongly agree Somewhat agree Somewhat disagree Strongly disagree N/A
23. Do you ever lack interest in having sex, but do it to please your partner?:	Strongly agree Somewhat agree Somewhat disagree Strongly disagree N/A
Any further comments:
Do you have any tips or useful strategies to help the development of the book?:
Do you have a positive/negative/intriguing story about self esteem that you would like to discuss with us as a possible case study for the book?: