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?
Several times a week
Are you presently employed? If yes, what is your occupation?
Were you employed previously? If yes, when and where?
Yes, Food service
What conditions have you been diagnosed with? When? Where?
Bi Polar Type II Personality Disorder NOS Alchohol and Drug Addiction
Have you ever been hospitalized? If yes, how many times? When was the last time that you were hospitalized?
Yes...15-20 times. I was last hospitalized for detox from alcohol and drugs
Please describe everything you know about your condition(s) and how you obtained such information?
I know that I have severe emotional mood swings, and obsessions. I also know that I have a personality disorder. I am also a recovering alcohol and drug addict. I came to know this through my treatment team. (Psychiatrist, Therapist, Case Managers)
Please illustrate your life before, during, and after learning of your condition(s) and engaging in therapies, if any?
Before I learned about my condition, my life was out of control.. going from one drug to the next. I was experiencing severe mood problems, and I attempted suicide several times. At first I drifted in and out of the hospitals, and was resistant to outpatient treatment. Since starting outpatient therapy, I have come face to face with my condition and am actively working with my treatment team, to keep the symptoms under control.
Please describe how you cope with your condition(s), if at all, and the effectiveness of each strategy?
I use a lot of self talk. I attend counseling regularly, and I use medications to stabilize my moods.
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...I have no trouble engaging others in conversation, I just feel as though they talk about me behind my back. I also feel as though others don't seem to genuinely like me. They just tolereate my prescence for the time being.
How do you envision your future?
Bleak. I have already messed up my life, and I don't see any improvement. Although, I continue with treatment efforts, hoping that I will prove myself wrong.
On the whole, I am satisfied with myself.
Strongly Disagree
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.
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:
Almost always tense
Almost always uncomfortable
Often in agony
More often distraught
Almost always discouraged
Almost always unsure
Almost always helpless
Almost always uncertain
My relationships help me feel I am:
Often worthless
Often distressed
Often distant
Often isolated
Often excluded
Often blamed
Often criticized
Towards those who are emotionally close to me, I feel I am:
Often resentful
Often welcoming
Often accepting
Often encouraging
Often trusting
Often understanding
Equally respectful and disrespectful
Universal beliefs and principles or a divine presence help me feel I am:
Often inspired
Equally comforted and troubled
More often judged
Often guided
Equally embraced and rejected
Equally in harmony and out-of-step
More often adrift
Towards universal beliefs and principles or a divine presence I feel I am:
Often listening
Often receptive
Often thankful
Often accepting
Often approaching
Often willing
Often separating