First Name
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Age Group
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Gender
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City
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State
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Zip Code
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Marital Status
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How many people share the living space with you?
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What is your highest level of formal education?
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What race/ethnicity do you belong to?
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What is the frequency of your visits to the health care provider?
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Are you presently employed? If yes, what is your occupation?
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Were you employed previously? If yes, when and where?
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What conditions have you been diagnosed with? When? Where?
| Bi Polar Type II Personality Disorder NOS Alchohol and Drug Addiction |
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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 |
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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) |
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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. |
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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. |
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Does the state of your health impede in any way your everyday activities such as work, housework, studies and so on?
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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?
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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. |
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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. |
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On the whole, I am satisfied with myself.
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At times I think I am no good at all.
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I feel that I have a number of good qualities.
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I am able to do things as well as most other people.
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I feel I do not have much to be proud of.
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I certainly feel useless at times.
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I feel that I'm a person of worth, at least on an equal plane with others.
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I wish I could have more respect for myself.
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All in all, I am inclined to feel that I am a failure.
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I take a positive attitude toward myself.
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I can always manage to solve difficult problems if I try hard enough.
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If someone opposes me, I can find the ways and means to get what I want.
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I am certain that I can accomplish my goals.
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I am confident that I could deal efficiently with unexpected events.
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Thanks to my resourcefulness, I can handle unforeseen situations.
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I can solve most problems if I invest the necessary effort.
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I can remain calm when facing difficulties because I can rely on my coping abilities.
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When I am confronted with a problem, I can find several solutions.
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If I am in trouble, I can think of a good solution.
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I can handle whatever comes my way.
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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 |
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My relationships help me feel I am:
| Often worthless | | Often distressed | | Often distant | | Often isolated | | Often excluded | | Often blamed | | Often criticized |
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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 |
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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 |
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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 |
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