First Name
Age Group
Zip Code
Marital Status
How many people share the living space with you?
What is your highest level of formal education?
High School
What race/ethnicity do you belong to?
What is the frequency of your visits to the health care provider?
Are you presently employed? If yes, what is your occupation?
Were you employed previously? If yes, when and where?
I was employed as a clerk at a pharmacy/drugstore in Nebraska.
What conditions have you been diagnosed with? When? Where?
Anorexia Nervosa in January 2002 at Children\'s Hospital in Omaha, NE Moderate depression and insomnia in November 2004 at Physician\'s Clinic in Omaha, NE
Have you ever been hospitalized? If yes, how many times? When was the last time that you were hospitalized?
Please describe everything you know about your condition(s) and how you obtained such information?
Information obtained through personal research on causes, effects, behaviors, symptoms, and treatments of anorexia. Information on relationship between chemical depression and insomnia, and on the way in which antidepressents work to alter chemical imbalances in the brain
Please illustrate your life before, during, and after learning of your condition(s) and engaging in therapies, if any?
Life is usually busy, fast-paced, and stressful. Often take on too many tasks. Has not changed during or after psychotherapy
Please describe how you cope with your condition(s), if at all, and the effectiveness of each strategy?
Positive self-talk to combat negative image of self related to body dysmorphic disorder and anorexia, rarely effective. Antidepressents for depression, usually very effective. Sedatives for insomnia, 50% effective
Does the state of your health impede in any way your everyday activities such as work, housework, studies and so on?
Sometimes makes it difficult to concentrate, especially on studying.
Does the state of your health impede in any way your social activities, such as inviting others to your residence, accepting invitations, going out with friends and so on?
Anorexia often prevents the accepting of lunch or dinner invitations, going to places with friends where food is likely.
How would you classify your daily interactions with people in general? (Comfortable, neutral, awkward, unpleasant) Please describe in detail.
General daily interactions are often tense and uncomfortable, usually focusing on how to best please the other person.
How do you envision your future?
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.
Strongly Agree
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.
Strongly Agree
All in all, I am inclined to feel that I am a failure.
I take a positive attitude toward myself.
Strongly Disagree
I can always manage to solve difficult problems if I try hard enough.
If someone opposes me, I can find the ways and means to get what I want.
I am certain that I can accomplish my goals.
I am confident that I could deal efficiently with unexpected events.
Thanks to my resourcefulness, I can handle unforeseen situations.
Strongly Disagree
I can solve most problems if I invest the necessary effort.
I can remain calm when facing difficulties because I can rely on my coping abilities.
When I am confronted with a problem, I can find several solutions.
Strongly Agree
If I am in trouble, I can think of a good solution.
I can handle whatever comes my way.
With my illness experience, I feel I am:
More often tense
Often uncomfortable
Often at ease
More often composed
Often discouraged
Equally confident and unsure
More often capable
Often certain
My relationships help me feel I am:
More often valued
Equally comforted and distressed
Equally close and distant
Equally connected and isolated
Often excluded
Often blamed
More often criticized
Towards those who are emotionally close to me, I feel I am:
Almost always forgiving
Almost always welcoming
Almost always accepting
Almost always encouraging
More often distrusting
Almost always understanding
Almost always respectful
Universal beliefs and principles or a divine presence help me feel I am:
More often uninspired
More often troubled
Often judged
Equally guided and aimless
Equally embraced and rejected
Often out-of-step
Often adrift
Towards universal beliefs and principles or a divine presence I feel I am:
More often ignoring
More often closed
More often thankful
Often accepting
Often receding
Often resisting
Equally connecting and separating