Skip to content
Askalot

← All Healthcare templates

Questionnaire template

Self-Esteem and Its Influences

Measures adults' global self-esteem with the Rosenberg scale plus the life areas and outside factors that shape it.

Preview

Healthcare · Personality tests. All Healthcare templates

Questions in this template

How You See Yourself

  1. Thank you for taking a few minutes to share how you see yourself. The survey is anonymous and helps us understand self-esteem and what influences it.

  2. The first set of statements is the Rosenberg Self-Esteem Scale, developed by Morris Rosenberg (1965).

  3. Your answers give a general picture of self-esteem. They are not a psychological assessment or a diagnosis.

  4. Below is a list of statements dealing with your general feelings about yourself. Please indicate how strongly you agree or disagree with each statement.

    • On the whole, I am satisfied with myself.
    • At times I think I am no good at all.
    • I feel that I have a number of good qualities.
    • I am able to do things as well as most other people.
    • I feel I do not have much to be proud of.
    • I certainly feel useless at times.
    • I feel that I'm a person of worth, at least on an equal plane with others.
    • I wish I could have more respect for myself.
    • All in all, I am inclined to feel that I am a failure.
    • I take a positive attitude toward myself.

    For each row: choose one:

    • Strongly agree
    • Agree
    • Disagree
    • Strongly disagree

  5. In which parts of your life do you feel most self-assured? Select all that apply.

    Choose any that apply:

    • Work
    • Social life
    • Family
    • Sport and exercise
    • Other
    • None of these

  6. Which other part of your life did you have in mind?

    Condition: Shown when Other was selected

    Open answer

Reacting to Criticism

  1. When someone criticises you, what effect does it usually have on how you see yourself?

    Choose one:

    • It strongly shakes my view of myself
    • It bothers me for a short while
    • I treat it as useful feedback
    • It has no effect on me

Outside Influences

  1. Which of these outside factors affect how you feel about yourself? Select all that apply.

    Choose any that apply:

    • Stress at work
    • Relationships
    • Body image
    • Social media
    • None of these

  2. If you are comfortable doing so, describe an experience that changed how you feel about yourself (optional).

    Open answer