12.07.2015 Views

Process - Physician - Fraser Health Authority

Process - Physician - Fraser Health Authority

Process - Physician - Fraser Health Authority

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Self-Assessment QuestionnaireName: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Date: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Please rate how well each of the statements below describes your usual way ofinteracting with your world.0 = Never or rarely true to me; 1 = Somewhat true; 2 = Quite a bit true; 3 = Very true of me.1 . . . . . It’s hard for me to say no to people even if I don’t want to agree or don’t havethe time or energy.2 . . . . . I will do almost anything to avoid hurting people’s feelings, whatever the costto myself.3 . . . . . I do lots of things for others, even at the expense of meeting my own needs.4 . . . . . Sometimes I am overwhelmed by things I do for others and have no life ortime of my own.5 . . . . . I am not con dent about expressing my ideas or opinions to others.6 . . . . . Sometimes I think people take advantage of my willingness to help.7 . . . . . I am afraid that people would not like me if I said “no” to them.8 . . . . . I get very upset if I can’t keep things organized and in control.9 . . . . . I always take on extra tasks, and am known for being ef cient.10 . . . . . I push myself to always do my best at everything — I hate making mistakes.CONTINUED ON NEXT PAGECBIS MANUAL | MAY 2009ASSESSMENT | 2331

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