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?
High School
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. waitress.
Were you employed previously? If yes, when and where?
What conditions have you been diagnosed with? When? Where?
Bipolar 2 Disorder, post traumatic stress disorder (PTSD)
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?
I was just diagnosed; I do not have much information.
Please illustrate your life before, during, and after learning of your condition(s) and engaging in therapies, if any?
I became depressed many years ago when I was 21 years old. It started after I had flashbacks to my childhood where it began to show me I was molested by someone. For a couple of years I ignored it all. I began sleeping all day and felt very bad about myself. Now I have so much build up in me I xlpode into a crying rage and I cant concentrate on anything. Everything I see makes me cry then i am ok for a few hours then it starts all over again. I have been diagnosed now as if yestarday and I am having a hard time understanding any of this. I am seeing a Psychologist.
Please describe how you cope with your condition(s), if at all, and the effectiveness of each strategy?
I dont know how to cope.......
Does the state of your health impede in any way your everyday activities such as work, housework, studies and so on?
Yes....I can't function in anything i do. I dont trust what people tell me,my mind keeps thinking about everything over and over again and i feel like my life is falling apart
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?
Oh yes
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?
I hope my therapist will help me get better so my family doesn't suffer
On the whole, I am satisfied with myself.
Strongly Disagree
At times I think I am no good at all.
Strongly Agree
I feel that I have a number of good qualities.
Strongly Disagree
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 Agree
I feel that I'm a person of worth, at least on an equal plane with others.
Strongly Disagree
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.
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.
Strongly Agree
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.
Strongly Agree
I can handle whatever comes my way.
Strongly Agree
With my illness experience, I feel I am:
Almost always tense
More often uncomfortable
More often in agony
More often distraught
More often discouraged
Almost always unsure
More often helpless
Almost always uncertain
My relationships help me feel I am:
More often worthless
Equally comforted and 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:
Almost always resentful
Equally welcoming and unreceptive
More often accepting
Almost always encouraging
Almost always distrusting
Equally understanding and misunderstanding
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
More often rejected
More often out-of-step
More often adrift
Towards universal beliefs and principles or a divine presence I feel I am:
Almost always listening
Almost always receptive
Often thankful
Equally accepting and critical
Almost always approaching
Almost always willing
Equally connecting and separating