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Personal Information

Name: ___________________________
Phone: ___________________________

Rating Scale

Each item is rated using the following scale:

  • 2 – Definitely Present
  • 1 – Possibly Present
  • 0 – Definitely Absent

Checklist Items

Section 1

  1. Glibness / Superficial Charm
  2. Previous Diagnosis as Psychopath (or Similar)
  3. Egocentricity / Grandiose Sense of Self-Worth
  4. Proneness to Boredom / Low Frustration Tolerance
  5. Pathological Lying and Deception
  6. Conning / Lack of Sincerity
  7. Lack of Remorse or Guilt
  8. Lack of Affect and Emotional Depth
  9. Callous or Lack of Empathy
  10. Parasitic Lifestyle
  11. Short-Tempered / Poor Behavioral Controls

Section 2

  1. Promiscuous Sexual Relations
  2. Early Behavior Problems
  3. Lack of Realistic, Long-Term Plans
  4. Impulsivity
  5. Irresponsible Behavior as a Parent
  6. Frequent Marital Relationships
  7. Juvenile Delinquency
  8. Poor Probation or Parole Risk
  9. Failure to Accept Responsibility for Own Actions
  10. Many Types of Offense
  11. Drug or Alcohol Abuse Not Direct Cause of Antisocial Behavior

Scoring System

  • Definitely Present = 2 points
  • Possibly Present = 1 point
  • Definitely Absent = 0 points

Total Score: __________

Score Interpretation

0–8 Points

Not Present

If the trait or behavior described is not evident in the individual being assessed. This means that the characteristic is not a notable aspect of their personality or behavior.

9–15 Points

Partial or Limited

Given that there is a partial match or a limited degree of the trait or behavior. The characteristic is present to some extent but is not a dominant or defining feature of the individual’s personality.

16–22 Points

Present

A score in this range indicates that the traits or behaviors are strongly present. These characteristics are notable and consistent aspects of the individual’s personality or behavior.

Additional Information (From Original Document)

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