First Name
|
Age Group
|
Gender
|
City
|
State
|
Zip Code
|
Marital Status
|
How many people share the living space with you?
|
What is your highest level of formal education?
|
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?
|
What conditions have you been diagnosed with? When? Where?
| Bipolar disorder (10 yrs, Canada) anorexia (2 yrs, Canada) |
|
Have you ever been hospitalized? If yes, how many times? When was the last time that you were hospitalized?
| Yes, dozens of times, most recent 3 weeks ago. |
|
|
|
|
Please describe everything you know about your condition(s) and how you obtained such information?
| You've got to be kidding. "Everything you know"? I could write a book. How I obtained it: doctors, books, internet, tv, print media, charities, hospitals, support groups, podcasts, videos, and more. |
|
Please illustrate your life before, during, and after learning of your condition(s) and engaging in therapies, if any?
| These questions are far too vague, open-ended and potentially time-consuming. "Illustrate your life" can mean anything. |
|
Please describe how you cope with your condition(s), if at all, and the effectiveness of each strategy?
|
Does the state of your health impede in any way your everyday activities such as work, housework, studies and so on?
|
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?
|
How would you classify your daily interactions with people in general? (Comfortable, neutral, awkward, unpleasant) Please describe in detail.
| Awkward. Avoid social situations when manic or depressed. |
|
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.
|
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.
|
All in all, I am inclined to feel that I am a failure.
|
I take a positive attitude toward myself.
|
|
|
|
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.
|
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.
|
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:
| Often tense | | Equally comfortable and uncomfortable | | More often at ease | | More often composed | | Often optimistic | | Almost always confident | | Almost always capable | | More often certain |
|
My relationships help me feel I am:
| Almost always worthless | | More often distressed | | Almost always distant | | Almost always isolated | | Almost always excluded | | Often supported | | Often accepted |
|
Towards those who are emotionally close to me, I feel I am:
| Almost always forgiving | | Equally welcoming and unreceptive | | Often accepting | | More often encouraging | | Almost always distrusting | | Equally understanding and misunderstanding | | Equally respectful and disrespectful |
|
| Universal beliefs and principles or a divine presence help me feel I am:
|
| Towards universal beliefs and principles or a divine presence I feel I am:
|
