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?
Bachelor Degree
What race/ethnicity do you belong to?
What is the frequency of your visits to the health care provider?
Are you presently employed? If yes, what is your occupation?
Yes, self-employed graphic artist
Were you employed previously? If yes, when and where?
Yes, 2000-2004, but I would prefer if that remained private.
What conditions have you been diagnosed with? When? Where?
anxiety, depression and severe mood swings by my GP here in town in 2003
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.
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.
At times I think I am no good at all.
Strongly Agree
I feel that I have a number of good qualities.
Strongly Agree
I am able to do things as well as most other people.
Strongly Agree
I feel I do not have much to be proud of.
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.
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.
Strongly Disagree
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.
I am confident that I could deal efficiently with unexpected events.
Strongly Disagree
Thanks to my resourcefulness, I can handle unforeseen situations.
Strongly Disagree
I can solve most problems if I invest the necessary effort.
Strongly Disagree
I can remain calm when facing difficulties because I can rely on my coping abilities.
When I am confronted with a problem, I can find several solutions.
Strongly Disagree
If I am in trouble, I can think of a good solution.
I can handle whatever comes my way.
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
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
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
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
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