Here’s a structured survey form based on the extracted items from your PDF:
Self-Perception Survey Form
Instructions
Please read each statement carefully and select the option that best represents your
agreement.
For each statement, choose:
A - If you agree with the first statement
B - If you agree with the second statement
Section 1: Personal Beliefs & Self-Perception
1. A. I feel I must always tell the truth.
B. I do not always tell the truth.
2. A. I feel I must strive for success in everything I undertake.
B. I do not feel that I must strive for success in everything.
3. A. I am afraid to be myself.
B. I am not afraid to be myself.
4. A. I feel guilty when I am selfish.
B. I don’t feel guilty when I am selfish.
5. A. For me, anything is possible if I believe in myself.
B. I have a lot of natural limitations, even though I believe in myself.
6. A. I sometimes feel embarrassed by compliments.
B. I am not embarrassed by compliments.
7. A. I accept my weaknesses.
B. I don’t accept my weaknesses.
8. A. Sometimes I am cross when I am not feeling well.
B. I am hardly ever cross.
9. A. I am afraid of making mistakes.
B. I am not afraid of making mistakes.
10. A. My feelings of self-worth depend on how much I accomplish.
B. My feelings of self-worth do not depend on how much I accomplish.
11. A. I fear failure.
B. I don’t fear failure.
12. A. It is possible to live life in terms of what I want to do.
B. It is not possible to live life in terms of what I want to do.
13. A. I can cope with the ups and downs of life.
B. I cannot cope with the ups and downs of life.
Section 2: Values & Social Perspectives
14. A. I find that I have rejected many of the moral values I was taught.
B. I have not rejected any of the moral values I was taught.
15. A. I live in terms of wants, likes, dislikes, and values.
B. I don’t live in terms of wants, likes, dislikes, and values.
16. A. I trust my ability to size up a situation.
B. I do not trust my ability to size up a situation.
17. A. I believe I have an innate capacity to cope with life.
B. I do not believe I have an innate capacity to cope with life.
18. A. I must justify my actions in the pursuit of my own interests.
B. I need not justify my actions in the pursuit of my own interests.
19. A. I am bothered by fears of being inadequate.
B. I am not bothered by fears of being inadequate.
20. A. I often feel it necessary to defend my past actions.
B. I do not feel it necessary to defend my past actions.
21. A. Criticism threatens my self-esteem.
B. Criticism does not threaten my self-esteem.
22. A. It is important that others accept my point of view.
B. It is not necessary for others to accept my point of view.
23. A. I welcome criticism as an opportunity for growth.
B. I do not welcome criticism as an opportunity for growth.
24. A. I hardly ever gossip.
B. I gossip a little at times.
Section 3: Self-Expression & Growth
25. A. I feel free to reveal my weaknesses among friends.
B. I don’t feel free to reveal my weaknesses among friends.
26. A. I feel free to be myself and bear the consequences.
B. I don’t feel free to be myself and bear the consequences.
27. A. I hesitate to show my weaknesses among strangers.
B. I don’t hesitate to show my weaknesses among strangers.
28. A. I grow only by setting my sights on a high-level, socially approved goal.
B. I will continue to grow best by being myself.
29. A. I accept inconsistencies within myself.
B. I cannot accept inconsistencies within myself.
30. A. I try to be sincere but sometimes I fail.
B. I try to be sincere and I am sincere.
31. A. Self-interest is natural.
B. Self-interest is unnatural.
32. A. People should always repent their wrongdoings.
B. People need not always repent their wrongdoings.
33. A. When I really love myself, everybody will love me.
B. When I really love myself, there will still be those who won’t love me.
34. A. I am assertive and affirming.
B. I am not assertive and affirming.
35. A. It is a good idea to think about your greatest potential.
B. A person who thinks about his greatest potential gets confused.
36. A. I am self-sufficient.
B. I am not self-sufficient.
37. A. I feel certain and secure in my relationships with others.
B. I feel uncertain and insecure in my relationships with others.
38. A. I can accept my mistakes.
B. I cannot accept my mistakes.
39. A. I feel comfortable with less than perfect performance.
B. I feel uncomfortable with anything less than a perfect performance.
40. A. I can overcome any obstacle as long as I believe in myself.
B. I cannot overcome every obstacle even if I believe in myself.
Final Notes
Thank you for taking this survey! Your responses will help in understanding self-perception and
personal growth.
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