1. Do you have every intention of doing what you say but can’t get started,
wait too long to start or forget?

Yes No Sometimes

9. Does your significant other nag you about following through on things?

Yes No Sometimes

2. Do you miss deadlines at work and at home?

Yes No Sometimes

10. Do you avoid taking on more responsibility at work because you’re afraid of failing?

Yes No Sometimes

3. Do you struggle with depression?

Yes No Sometimes

11. Have you lost jobs because of performance problems?

Yes No Sometimes

4. Have relationships ended because the other person felt you kept letting them down?

Yes No Sometimes

12. Do you beat yourself up for not doing what you say you will?

Yes No Sometimes

5. Have you lost jobs because of performance problems?

Yes No Sometimes

13. Are you bored in your job?

Yes No Sometimes

6. Do you feel like a failure?

Yes No Sometimes

14. Do others tell say you’re smart and could do better if you just tried?

Yes No Sometimes

7. Have you had bills turned over to collections not because you couldn’t pay them but because you forgot to pay them?

Yes No Sometimes

15. Have you had addiction problems with gambling, porn, alcohol, drugs…?

Yes No Sometimes

8. Do you and your significant other fight a lot about your commitment to the relationship?

Yes No Sometimes

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