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?
Bachelor Degree
What race/ethnicity do you belong to?
What is the frequency of your visits to the health care provider?
Every Week
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.
Strongly Agree
I am able to do things as well as most other people.
Strongly Agree
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.
Strongly Agree
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.
Strongly Disagree
When I am confronted with a problem, I can find several solutions.
Strongly Disagree
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:
Almost always closed