1. Have I ever missed work or school due to shoplifting?

Y/N

2. Do I have trouble with my relationships because of shoplifting?

Y/N

3. Has shoplifting destroyed or become a serious issue in my marriage?

Y/N

4. Has shoplifting caused me to lose friends?

Y/N

5. Has shoplifting affected my reputation or what people think of me?

Y/N

6. Have I ever felt guilty or shameful after shoplifting?

Y/N

7. Has shoplifting ever caused me to cry?

Y/N

8. Did I ever sell items that I shoplifted to get money?

Y/N

9. Has shoplifting caused me feelings of anxiety or depression?

Y/N

10. Has shoplifting affected my work or school performance?

Y/N

11. Have I ever experienced an "adrenaline rush", a "high" , or feelings of an excited "thrill" when shoplifting?

Y/N

12. Have I ever used shoplifting to escape my problems or worries?

Y/N

13. Have I ever had trouble falling asleep due to shoplifting?

Y/N

14. Has shoplifting changed my normal life patterns such as eating, going to the bathroom, or functioning in any way?

Y/N

15. Has shoplifting ever caused me physical discomforts such as stomach aches, headaches, heartburn, etc.?

Y/N

16. Do frustrations, disappointments, and troubles at home  create an urge in me to shoplift?

Y/N

17. Has my shoplifting become more frequent over time?

Y/N

18. Have I ever had thoughts of suicide as a result of my shoplifting?

Y/N

19. Am I constantly preoccupied by thoughts of shoplifting?

Y/N

20. Do I pray for help and wish I could stop shoplifting?

Y/N

21. Have I ever told myself, "I'm done" or "This is my last time" and yet I still continued to shoplift?

Y/N

22. Do I keep my shoplifting a secret or feel that I lead a secret life?

Y/N

23. Do I harbor feelings of anger, resentment or the need to control?

Y/N

24. Do I feel that life is unfair or that I am the underdog?

Y/N

25. Do I feel that I am entitled to "get" what I want for nothing?

Y/N

26. Do I have trouble standing up for myself?

Y/N

27. Do I feel angry at myself when I say "yes" to something when I really want to say "no"?

Y/N

28. Have I ever been arrested for shoplifting?

Y/N

29. Do I continue to shoplift despite having been in legal trouble before?

Y/N

30. Am I in legal trouble now for shoplifting?

Y/N