This might be longer than what you are looking for but it's the one I use. That is when I "remember to"

http://www.thechangeworkscoaching.co...Sheet_Form.pdf

For me, when I'm asked to scale or rate things I always try to answer in around "I don't need help, I will be fine". Which in my opinion is right around 60% if 100% is great. So the scale, even though ranges 60%-100%, the bottom answer I will give is 60%. So with this one, it's hard for me to know where I'll end up on the scale because I printed it on the back. And there's no middle in 0-3 so I can't find that 60% answer.

I actually like yours though.