First Name
Age Group
New Hampshire
Zip Code
Marital Status
How many people share the living space with you?
What is your highest level of formal education?
Master Degree
What race/ethnicity do you belong to?
What is the frequency of your visits to the health care provider?
Every Month
Are you presently employed? If yes, what is your occupation?
yes psychotherapist for adolescent and young adult women
Were you employed previously? If yes, when and where?
same place 20 years
What conditions have you been diagnosed with? When? Where?
Bipolar2003 ARNP outpatient ; previously dx was major depression; Panic disorder 2003 Fibromyalgia 2004
Have you ever been hospitalized? If yes, how many times? When was the last time that you were hospitalized?
Please describe everything you know about your condition(s) and how you obtained such information?
Please illustrate your life before, during, and after learning of your condition(s) and engaging in therapies, if any?
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.
How do you envision your future?
On the whole, I am satisfied with myself.
Strongly Disagree
At times I think I am no good at all.
Strongly Disagree
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.
Strongly Disagree
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.
Strongly Agree
I am confident that I could deal efficiently with unexpected events.
Strongly Agree
Thanks to my resourcefulness, I can handle unforeseen situations.
Strongly Agree
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 Agree
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.
Strongly Agree
With my illness experience, I feel I am:
Almost always tense
More often uncomfortable
Often in agony
Often distraught
Almost always discouraged
More often unsure
Equally capable and helpless
Often uncertain
My relationships help me feel I am:
Often valued
Often comforted
Equally close and distant
Often connected
Often included
Often supported
Often accepted
Towards those who are emotionally close to me, I feel I am:
Equally forgiving and resentful
Equally welcoming and unreceptive
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:
Equally inspired and uninspired
Equally comforted and troubled
Equally accepted and judged
Equally guided and aimless
Equally embraced and rejected
Equally in harmony and out-of-step
Equally sustained and adrift
Towards universal beliefs and principles or a divine presence I feel I am:
Equally listening and ignoring
Equally receptive and closed
Equally thankful and demanding
Often critical
Equally approaching and receding
Often resisting
Equally connecting and separating