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?
| yes, but struggling, House painter |
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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?
| Bipolar mixed with rapid cycling |
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Have you ever been hospitalized? If yes, how many times? When was the last time that you were hospitalized?
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Please describe everything you know about your condition(s) and how you obtained such information?
| I know alot but am very confused, i've read everything i could find at the library |
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Please illustrate your life before, during, and after learning of your condition(s) and engaging in therapies, if any?
| all through my 20's my life felt out of control, iwas being treated for depression for most of my life, i've been in and out of therapy over the years. My life feels like it has not changed one bit, i just wanna be happy again and live life to its fullest |
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Please describe how you cope with your condition(s), if at all, and the effectiveness of each strategy?
| i struggle everyday to understand why i do the things i do! |
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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.
| sometimes confortable but mostly awkward |
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How do you envision your future?
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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:
| Often tense | | Equally comfortable and uncomfortable | | Often in agony | | Often distraught | | Often discouraged | | Often unsure | | Often helpless | | Often 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:
| Equally forgiving and resentful | | Often unreceptive | | Often rejecting | | Often discouraging | | Often distrusting | | Often misunderstanding | | Often disrespectful |
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Universal beliefs and principles or a divine presence help me feel I am:
| Often uninspired | | Often troubled | | Often judged | | Often aimless | | Often rejected | | Often out-of-step | | Often adrift |
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Towards universal beliefs and principles or a divine presence I feel I am:
| Often ignoring | | Often closed | | Often demanding | | Often critical | | Often receding | | Often resisting | | Often separating |
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