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, self-employed graphic artist |
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Were you employed previously? If yes, when and where?
| Yes, 2000-2004, but I would prefer if that remained private. |
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What conditions have you been diagnosed with? When? Where?
| anxiety, depression and severe mood swings by my GP here in town in 2003 |
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Have you ever been hospitalized? If yes, how many times? When was the last time that you were hospitalized?
| Yes, 11 years ago because of a suicide attempt. |
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Please describe everything you know about your condition(s) and how you obtained such information?
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Please illustrate your life before, during, and after learning of your condition(s) and engaging in therapies, if any?
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Please describe how you cope with your condition(s), if at all, and the effectiveness of each strategy?
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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.
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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:
| More often tense | | More often uncomfortable | | More often in agony | | Equally composed and distraught | | Equally optimistic and discouraged | | Equally confident and unsure | | Equally capable and helpless | | Equally certain and uncertain |
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My relationships help me feel I am:
| More often worthless | | Often distressed | | Equally close and distant | | Equally connected and isolated | | Equally included and excluded | | Equally supported and blamed | | Equally accepted and criticized |
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Towards those who are emotionally close to me, I feel I am:
| Often forgiving | | More often welcoming | | More often accepting | | More often encouraging | | Equally trusting and distrusting | | More often understanding | | Almost always respectful |
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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 | | More often adrift |
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Towards universal beliefs and principles or a divine presence I feel I am:
| More often listening | | More often receptive | | Often thankful | | Often accepting | | Often approaching | | Equally willing and resisting | | Equally connecting and separating |
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