Please print your answers.

ADULT SELF -REPORT FOR AGES 18-59 For office use only
ID#
YOUR First Middle Last YOUR USUAL TYPE OF WORK, even if not working now. Please be
FULL specific for example, auto technician; high school teacher; homemaker;
NAME laborer; lathe operator; shoe salesman; army sergeant; student (indicate
YOUR GENDER YOUR ETHNIC what you are studying & what degree you expect).
AGE GROUP
OR RACE Your Spouse or partner’s
work _____________________ work _________________________
TODAY’S DATE YOUR BIRTHDATE
PLEASE CHECK YOUR HIGHEST EDUCATION
Mo. _____ Date _____ Yr. _____ Mo. _____ Date _____ Yr. _____
q 1. No high school diploma and no GED q 7. Some graduate school
Please fill out this form to reflect your views, even if other q 2. General Equivalency Diploma (GED) but no graduate degree
people might not agree. You need not spend a lot of time on q 3. High school graduate q 8. Master’s Degree
any item. Feel free to print additional comments. Be sure to q 4. Some college but no college degree q 9. Doctoral or Law Degree
answer all items. q 5. Associate’s Degree q Other education (specify):
______________________
q 6. Bachelor’s or RN Degree
I. FRIENDS:
A. About how many close friends do you have? (Do not include family members.)

PY
q None q1 q 2 or 3 q 4 or more

T LE
B. About how many times a month do you have contact with any of your close friends? (Include in-person contacts, phone, letters, e-mail.)
q Less than 1 q 1 or 2 q 3 or 4 q 5 or more

O
C. How well do you get along with your close friends?
N MP
q Not as well as I’d like q Average q Above average q Far above average
C
D. About how many times a month do any friends or family visit you?
q Less than 1 q 1 or 2 q 3 or 4 q 5 or more
O A

II. SPOUSE OR PARTNER:

What is your marital status? q Never been married q Married but separated from spouse
S
O

q Married, living with spouse q Divorced

q Widowed q Other --- please describe:________________________

At any time in the past 6 months, did you live with your spouse or with a partner?

q No --- please skip to page 2.

q Yes --- Circle 0, 1, or 2 beside items A-H to describe your relationship during the past 6 months:
0 = Not True 1 = Somewhat or Sometimes True 2 = Very True or Often True
D

0 1 2 A. I get along well with my spouse or partner 0 1 2 E. My spouse or partner and I disagree about
living arrangements, such as where we live
0 1 2 B. My spouse or partner and I have trouble
sharing responsibilities 0 1 2 F. I have trouble with my spouse or partner’s family
0 1 2 C. I feel satisfied with my spouse or partner 0 1 2 G. I like my spouse or partner’s friends
0 1 2 D. My spouse or partner and I enjoy similar activities 0 1 2 H. My spouse or partner’s behavior annoys me

Copyright 2003 T. Achenbach Please be sure you have answered all items.
ASEBA, University of Vermont Then see other side.
www.ASEBA.org (09-30-21) 9-21 Edition - 111

UNAUTHORIZED COPYING IS ILLEGAL

Page 1
 Please print. Be sure to answer all items.

III. FAMILY:
Compared with others, how well do you: Worse than Variable or Better than No
Average Average Average Contact
A. Get along with your brothers? q I have no brothers q q q q
B. Get along with your sisters? q I have no sisters q q q q
C. Get along with your mother? q Mother is deceased q q q q
D. Get along with your father? q Father is deceased q q q q
E. Get along with your children? q I have no children
1. Oldest child q Not applicable q q q q
2. 2nd oldest child q Not applicable q q q q
3. 3rd oldest child q Not applicable q q q q
4. Other children q Not applicable q q q q
F. Get along with your stepchildren? q I have no stepchildren q q q q
IV. JOB: At any time in the past 6 months, did you have any paid jobs (including self-employment and military service)?
q No --- please skip to Section V.
q Yes --- please describe your job(s): ____________________________________________________

PY
Circle 0, 1, or 2 beside items A-I to describe your work experience during the past 6 months:

T LE
0 = Not True 1 = Somewhat or Sometimes True 2 = Very True or Often True
0 1 2 A. I work well with others 0 1 2 F. I do things that may cause me to lose my job
0 1 2 B. I have trouble getting along with bosses 0 1 2 G. I stay away from my job even when I’m not
sick or not on vacation

O
0 1 2 C. I do my work well
N MP
0 1 2 H. My job is too stressful for me
0 1 2 D. I have trouble finishing my work
0 1 2 E. I am satisfied with my work situation 0 1 2 I. I worry too much about work
C
V. EDUCATION: At any time in the past 6 months, did you attend school, college, or any other educational or training program?
q No --- please skip to section VI.
O A

q Yes--- What kind of school or program? _______________________________________________________________

What degree or diploma are you seeking?______________________________ Major? _________________________
When do you expect to receive your degree or diploma?__________________________________________________
S
O

Circle 0, 1, or 2 beside items A-E to describe your educational experience during the past 6 months:
0 = Not True 1 = Somewhat or Sometimes True 2 = Very True or Often True
0 1 2 A. I get along well with other students 0 1 2 D. I am satisfied with my educational situation
0 1 2 B. I achieve what I am capable of 0 1 2 E. I do things that may cause me to fail
0 1 2 C. I have trouble finishing assignments
VI. Do you have any illness, disability, or handicap? q No q Yes --- please describe:
D

VII. Please describe your concerns or worries about family, work, education, or other things: q No concerns

VIII. Please describe the best things about yourself:

Page 2 Please be sure you have answered all items.

 Please print your answers. Be sure to answer all items.
IX. Below is a list of items that describe people. For each item, please circle 0, 1, or 2 to describe yourself over
the past 6 months. Please answer all items as well as you can, even if some do not seem to apply to you.
0 = Not True 1 = Somewhat or Sometimes True 2 = Very True or Often True
0 1 2 1. I am too forgetful 0 1 2 37. I get in many fights
0 1 2 2. I make good use of my opportunities 0 1 2 38. My relations with neighbors are poor
0 1 2 3. I argue a lot 0 1 2 39. I hang around people who get in trouble
0 1 2 4. I work up to my ability 0 1 2 40. I hear sounds or voices that other people think
0 1 2 5. I blame others for my problems aren’t there (describe): _________________
0 1 2 6. I use drugs (other than alcohol or nicotine) for ___________________________________
nonmedical purposes (describe):___________
0 1 2 41. I am impulsive or act without thinking
_____________________________________
0 1 2 42. I would rather be alone than with others
0 1 2 7. I brag
0 1 2 8. I have trouble concentrating or paying 0 1 2 43. I lie or cheat
attention for long 0 1 2 44. I feel overwhelmed by my responsibilities
0 1 2 9. I can’t get my mind off certain thoughts 0 1 2 45. I am nervous or tense
(describe): ____________________________ 0 1 2 46. Parts of my body twitch or make nervous
_____________________________________ movements (describe): ________________

PY
0 1 2 10. I have trouble sitting still ___________________________________

T LE
0 1 2 11. I am too dependent on others 0 1 2 47. I lack self-confidence
0 1 2 12. I feel lonely 0 1 2 48. I am not liked by others
0 1 2 13. I feel confused or in a fog 0 1 2 49. I can do certain things better than other people

O
0 1 2 14. I cry a lot 0 1 2 50. I am too fearful or anxious
N MP
0 1 2 15. I am pretty honest
0 1 2 16. I am mean to others 0 1 2 51. I feel dizzy or lightheaded

0 1 2
0 1 2
C
17. I daydream a lot
18. I deliberately try to hurt or kill myself
0 1 2

0 1 2
52. I feel too guilty

53. I have trouble planning for the future

0 1 2 54. I feel tired without good reason
O A

0 1 2 19. I try to get a lot of attention

0 1 2 20. I damage or destroy my things 0 1 2 55. My moods swing between elation and
depression
S
O

0 1 2 21. I damage or destroy things belonging to others 56. Physical problems without known medical
0 1 2 22. I worry about my future cause:
0 1 2 23. I break rules at work or elsewhere 0 1 2 a. Aches or pains (not stomach or headaches)
0 1 2 24. I don’t eat as well as I should 0 1 2 b. Headaches
0 1 2 c. Nausea, feel sick
0 1 2 25. I don’t get along with other people 0 1 2 d. Problems with eyes (not if corrected by
0 1 2 26. I don’t feel guilty after doing something I glasses) (describe): ___________________
shouldn’t ___________________________________
0 1 2 27. I am jealous of others 0 1 2 e. Rashes or other skin problems
0 1 2 28. I get along badly with my family 0 1 2 f. Stomachaches
D

0 1 2 g. Vomiting, throwing up
0 1 2 29. I am afraid of certain animals, situations, or 0 1 2 h. Heart pounding or racing
places (describe): ______________________ 0 1 2 i. Numbness or tingling in body parts
______________________________________
0 1 2 57. I physically attack people
0 1 2 30. My social relations with other genders are poor 0 1 2 58. I pick my skin or other parts of my body
0 1 2 31. I am afraid I might think or do something bad (describe): __________________________
0 1 2 32. I feel that I have to be perfect ___________________________________

0 1 2 33. I feel that no one loves me 0 1 2 59. I fail to finish things I should do
0 1 2 34. I feel that others are out to get me 0 1 2 60. There is very little that I enjoy

0 1 2 35. I feel worthless or inferior 0 1 2 61. My work performance is poor

0 1 2 36. I accidentally get hurt a lot, accident-prone 0 1 2 62. I am poorly coordinated or clumsy
Page 3 Please be sure you have answered all items.
Then see other side.
 Please print your answers. Be sure to answer all items.
0 = Not True 1 = Somewhat or Sometimes True 2 = Very True or Often True
0 1 2 63. I would rather be with older people than 0 1 2 93. I talk too much
with people of my own age 0 1 2 94. I tease others a lot
0 1 2 64. I have trouble setting priorities
0 1 2 95. I have a hot temper
0 1 2 65. I refuse to talk 0 1 2 96. I think about sex too much
0 1 2 66. I repeat certain acts over and over
(describe): ___________________________ 0 1 2 97. I threaten to hurt people
____________________________________ 0 1 2 98. I like to help others
0 1 2 67. I have trouble making or keeping friends 0 1 2 99. I dislike staying in one place for very long
0 1 2 68. I scream or yell a lot 0 1 2 100. I have trouble sleeping (describe): ________
____________________________________
0 1 2 69. I am secretive or keep things to myself
0 1 2 70. I see things that other people think 0 1 2 101. I stay away from my job even when I’m not
aren’t there (describe):_________________ sick or not on vacation
____________________________________ 0 1 2 102. I don’t have much energy
0 1 2 71. I am self-conscious or easily 0 1 2 103. I am unhappy, sad, or depressed
embarrassed 0 1 2 104. I am louder than others
0 1 2 72. I worry about my family
0 1 2 105. People think I am disorganized

PY
0 1 2 73. I meet my responsibilities to my family 0 1 2 106. I try to be fair to others

T LE
0 1 2 74. I show off or clown
0 1 2 107. I feel that I can’t succeed
0 1 2 75. I am too shy or timid 0 1 2 108. I tend to lose things
0 1 2 76. My behavior is irresponsible

O
0 1 2 109. I like to try new things
N MP
0 1 2 77. I sleep more than most other people during 0 1 2 110. I wish I were of a different gender
day and/or night (describe): _____________
____________________________________
C 0 1 2 111. I keep from getting involved with others
0 1 2 78. I have trouble making decisions 0 1 2 112. I worry a lot

0 1 2 79. I have a speech problem (describe):_______ 0 1 2 113. I worry about my social relations with
O A

other genders
____________________________________ 0 1 2 114. I fail to pay my debts or meet other
0 1 2 80. I stand up for my rights financial responsibilities
S
O

0 1 2 81. My behavior is very changeable 0 1 2 115. I feel restless or fidgety

0 1 2 82. I steal 0 1 2 116. I get upset too easily

0 1 2 83. I am easily bored 0 1 2 117. I have trouble managing money or credit

0 1 2 84. I do things that other people think are cards
strange (describe): _____________________ 0 1 2 118. I am too impatient
____________________________________
0 1 2 119. I am not good at details
0 1 2 85. I have thoughts that other people would 0 1 2 120. I drive too fast
think are strange (describe): _____________
0 1 2 121. I tend to be late for appointments
D

____________________________________
0 1 2 122. I have trouble keeping a job
0 1 2 86. I am stubborn, sullen, or irritable
0 1 2 123. I am a happy person
0 1 2 87. My moods or feelings change suddenly
0 1 2 88. I enjoy being with people 124. In the past 6 months, about how many times per day
did you use tobacco (including smokeless tobacco)
0 1 2 89. I rush into things without considering or use e-cigarettes? ___________ times per day.
the risks
0 1 2 90. I drink too much alcohol or get drunk 125. In the past 6 months, on how many days
were you drunk? ___________ days.
0 1 2 91. I think about killing myself 126. In the past 6 months, on how many days did you
0 1 2 92. I do things that may cause me trouble with use drugs for nonmedical purposes (including
the law (describe): ____________________ marijuana, cocaine, and other drugs, except alcohol
____________________________________ and nicotine)? _________ days.

Page 4 Please be sure you have answered all items.