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* 1. In an average year, how often were you disciplined physically OR “yelled at” as a child when - if you look back in retrospect now - your mistake seemed minor or innocent?

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* 2. Using the same scale, how frequently were you the target of physical discipline, strong words and/or a loud tone of voice from the following figures:

  Never Once a year or less During a year but less than monthly Monthly Weekly Daily Not Applicable
Dad
Mom
Step-dad
Step-mom
Male teacher(s)
Female teacher(s)
Male coach(es)
Female coach(es)
Other

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* 3. Describe the average level of intensity of the correction you received as a child from the following people:

  Gentle Mild Firm but fair Somewhat strong Very strong Not applicable
Dad
Mom
Step-dad
Step-mom
Male teacher(s)
Female teacher(s)
Male coach(es)
Female coach(es)

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* 4. Describe how consistent the intensity of the correction you received as a child was from the following people:

  Extremely consistent Very consistent Consistent Occasionally inconsistent Inconsistent Very inconsistent Extremely inconsistent
Dad
Mom
Step-dad
Step-mom
Male teacher(s)
Female teacher(s)
Male coach(es)
Female coach(es)
Other

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* 5. As an adult, how frequently would you say you criticize yourself for the way you behave?

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* 6. If you criticize your own behavior how hard would you say you generally are with yourself?

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* 7. If you are or have been a parent, how frequently would you say you strongly criticize(d) the way one or more of your kids behave(d)?

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* 8. If you are a parent and criticize your child’s/children’s behavior how hard would you say you generally are with them?

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* 9. In your family growing up, how would you describe the relative toughness of your father/dad on you and your siblings? My father/dad was:

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* 10. In your family growing up, how would you describe the relative toughness of your mother/mom on you and your siblings? My mother/mom was:

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* 11. For demographic purposes. I am:

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* 12. My parents raised us during the (check all that apply)

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* 13. I raised my child(ren) during the (check all that apply)

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* 14. If you happen to know your Myers-Briggs type please indicate it below (for refresher purposes: E/I are for Extravert/Introvert; S/N are for Sensing/Intuiting; T/F are for Thinking/Feeling; and J/P are for Judging/Perceiving

T