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?
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?
Yes, telephone operator; pet sales; video store clerk. All before 1999.
What conditions have you been diagnosed with? When? Where?
BiPolar II, anxiety, depression, PMD, osteoarthritis, chronic pain in back and feet.
Have you ever been hospitalized? If yes, how many times? When was the last time that you were hospitalized?
Not for mental problems.
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.
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.
Strongly Agree
All in all, I am inclined to feel that I am a failure.
Strongly Agree
I take a positive attitude toward myself.
Strongly Disagree
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.
Strongly Agree
I am certain that I can accomplish my goals.
Strongly Agree
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 Agree
When I am confronted with a problem, I can find several solutions.
Strongly Agree
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
Almost always uncomfortable
Almost always in agony
Almost always distraught
Almost always discouraged
Almost always unsure
Almost always helpless
Almost always uncertain
My relationships help me feel I am:
More often valued
More often distressed
More often distant
More often isolated
More often included
More often supported
More often accepted
Towards those who are emotionally close to me, I feel I am:
More often resentful
More often unreceptive
More often rejecting
More often discouraging
More often distrusting
More often misunderstanding
More often disrespectful
Universal beliefs and principles or a divine presence help me feel I am:
More often uninspired
Almost always troubled
Almost always judged
Almost always aimless
Almost always out-of-step
Almost always adrift
Towards universal beliefs and principles or a divine presence I feel I am:
Equally listening and ignoring
Equally receptive and closed
Almost always thankful
More often accepting
More often receding
More often willing
More often separating