Part A
Nationality Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegowina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocoa (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote DivoireCroatia (Hrvatska) Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France France, Metropolitan French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard and Mc Donald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran (Islamic Republic of) Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, Democratic Peoples Republic of Korea, Republic of Kuwait Kyrgyzstan Lao Peoples Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Macedonia, The Former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Moldova, Republic of Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal PuertoRico Qatar Reunion Romania Russian Federation Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa SanMarino Sao Tome and Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia (Slovak Republic) Slovenia Solomon Islands Somalia South Africa SouthGeorgia and the South Sandwich Islands Spain Sri Lanka St. Helena St. Pierre andMiquelon Sudan Suriname Svalbard and Jan Mayen Islands Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania, United Republic of Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City State(Holy See) Venezuela Viet Nam Virgin Islands (British) Virgin Islands (U.S.) Wallis and Futuna Islands Western Sahara Yeman Yugoslavia Zaire Zambia Zimbabwe If British Please Use Specific Box
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Age 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 Gender Male Female Are You single cohabiting married separated widowed Instructions:
The following statements refer to your feelings, actions, and perceptions in general . Please try as much as possible describe your habitual behaviour patterns and attitudes by selecting through one of the four alternatives. Please use the following scale:
(1) strongly disagree
(2) moderately disagree
(3) moderately agree
(4) strongly agree
For example:
I am a cheerful person.............................................................................................. (1) (2) (3) (4)
If you strongly agree with this statement, that is, if you are in general a cheerful person, Select through (4) . If you strongly disagree, that is, if you are habitually not cheerful at all , Select through (1) . If you have difficulty answering a question, pick the response that most applies.
Please answer every question, do not omit any.
1 When they laugh in my presence I get suspicious (1) (2) (3) (4) 2 I avoid displaying myself in public because I fear that people could become aware of my insecurity and could make fun of me. (1) (2) (3) (4) 3 When strangers laugh in my presence I often relate this to me personally. (1) 2( ) (3) (4) 4 When others make joking remarks about me I feel being paralyzed. (1) (2) (3) (4) 5 I control myself strongly in order not to attract negative attention so I do not make a ridiculous impression. (1) (2) (3) (4) 6 I believe that I make a funny impression on others. (1) (2) (3) (4) 7 Although I frequently feel lonely, I have the tendency not to share social activities in order (1) (2) (3) (4) 8 When I have made an embarrassing impression somewhere, I avoid the place thereafter. (1) (2) (3) (4) 9 If I did not fear making a fool of myself I would speak much more in public. (1) (2) (3) (4) 10 If someone has teased me in the past I cannot deal freely with him forever. (1) (2) (3) (4) 11 It takes me very long to recover from having been laughed at. (1) (2) (3) (4) 12 While dancing I feel uneasy because I am convinced that those watching me assess me as being ridiculous. (1) (2) (3) (4) 13 Especially when I feel relatively unconcerned, the risk is high for me to attract negative attention and appear peculiar to others. (1) (2) (3) (4) 14 When others tease me, I lose control or the ability to adequately coordinate my motions. (1) (2) (3) (4) 15 When I have made a fool of myself in front of others I grow completely stiff and lose my ability to behave adequately. (1) (2) (3) (4) Part B
Please check to see that you have answered every statement that you want to.
1. Please describe an example of the MOST INTENSE experience of FEAR you can imagine that any human being has ever felt. Your example can be about someone you know, or it could be based on someone in the new, in a movie or TV programme. It can be something you have read or just something you imagine.
Write below your example of the MOST INTENSE FEAR you imagine anyone in the world has ever felt:
If the FEAR felt by the person in your example is rated �8� the most intense FEAR YOU have ever felt is? (Please select a number)
0 1 2 3 4 5 6 7 8
Least Most
Keeping in mind a time when you felt extremely FEARFUL.
A. How quickly did those extremely FEARFUL feelings begin? (Please select one)
0 1 2 3 4 5 6 7 8
Almost Immediately few minutes took a long time
B How long did it take you to get over those extremely FEARFUL feelings?
0 1 2 3 4 5 6 7 8
Minutes Hours Days Weeks Months
C. Some people show their feelings more than others. When you are feeling extremely FEARFUL , does your voice and facial expressions show how you are feeling? (Please select one)
0 1 2 3 4 5 6 7 8
Not Slightly quite a lot very much at all
2 . Please describe an example of the MOST INTENSE experience of HAPPINESS you can imagine that any human being has ever felt. Your example can be about someone you know, or it could be based on someone in the new, in a movie or TV programme. It can be something you have read or just something you imagine.
Write below your example of the MOST INTENSE HAPPINESS you imagine anyone in the world has ever felt:
If the HAPPINESS felt by the person in your example is rated �8� the most intense HAPPINESS YOU have ever felt is? (Please select a number)
0 1 2 3 4 5 6 7 8
Least Most
Keeping in mind a time when you felt extremely HAPPY.
A. How quickly did those extremely HAPPY feelings begin? (Please select one)
0 1 2 3 4 5