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?
Yes, for a check cashing and payday loan company
What conditions have you been diagnosed with? When? Where?
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?
did a web search on depression and living in a dirty house, also fear of letting anyone in my home
Please illustrate your life before, during, and after learning of your condition(s) and engaging in therapies, if any?
I was happily married, life was good wonderful even. My husband left when I found out I had cancer, stating he is gay. I am cancer free now. I have never been diagnosed. Have been treated for anxiety in 2003 used effexor, no therapy
Please describe how you cope with your condition(s), if at all, and the effectiveness of each strategy?
I dont cope ... I beat myself up
Does the state of your health impede in any way your everyday activities such as work, housework, studies and so on?
walking into my house is like walking into a huge trash can that has never been emptied. I tell myself it is ok to clean it .. it will be alright ... but can never manage to do it.
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?
I dont go out. I am frightened to let anyone in.
How would you classify your daily interactions with people in general? (Comfortable, neutral, awkward, unpleasant) Please describe in detail.
on a professional basis I would say neutral, on a personal basis I do every thing I can to avoid it.
How do you envision your future?
I dont. I just cant see beyond today and am scared of tomorrow.
On the whole, I am satisfied with myself.
At times I think I am no good at all.
Strongly Agree
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.
Strongly Agree
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.
Strongly Disagree
I wish I could have more respect for myself.
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.
Strongly Agree
If someone opposes me, I can find the ways and means to get what I want.
Strongly Agree
I am certain that I can accomplish my goals.
I am confident that I could deal efficiently with unexpected events.
Strongly Agree
Thanks to my resourcefulness, I can handle unforeseen situations.
I can solve most problems if I invest the necessary effort.
Strongly Agree
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.
Strongly Agree
I can handle whatever comes my way.
Strongly Agree
With my illness experience, I feel I am:
Almost always tense
Almost always uncomfortable
Almost always in agony
Almost always distraught
Almost always discouraged
Almost always unsure
Almost always helpless
Almost always uncertain
My relationships help me feel I am:
Often worthless
More often distressed
Almost always distant
Almost always isolated
More often excluded
Often blamed
Often criticized
Towards those who are emotionally close to me, I feel I am:
Equally forgiving and resentful
More often unreceptive
More often rejecting
More often discouraging
Almost always distrusting
Almost always misunderstanding
Equally respectful and disrespectful
Universal beliefs and principles or a divine presence help me feel I am:
Often uninspired
More often troubled
Almost always judged
Almost always aimless
Often rejected
Almost always out-of-step
Almost always adrift
Towards universal beliefs and principles or a divine presence I feel I am:
Equally listening and ignoring
Equally receptive and closed
More often demanding
More often critical
More often receding
Equally willing and resisting
Almost always separating