Home
Appointments & Referrals
Services
Appointment Fees
About
Patient Resource
Home
Appointments & Referrals
Services
Appointment Fees
About
Patient Resource
Form F60: A-C
Open Form
F60: A-C
Patient ID
*
This has been provided to you with the link to this form in order to keep your name anonymous as this website lacks proper encryption for HIPAA compliance.
2) Do others tell you your moods seem to change a lot?
*
Yes
No
3) Do you often have days when your mood seems to rapidly shift from feeling "normal" or at your baseline to feeling irritable/agitated, depressed, anxious or angry?
*
Yes
No
1) Would you describe yourself as often feeling empty?
*
Yes
No
4) Have you made desperate efforts to avoid feeling or being abandoned?
*
Yes
No
5) With certain people do you sometimes switch pretty extremely from loving or respecting them at times to despising them at other times?
*
Yes
No
6) Do your relationships with friends and partners tend to be intense with a lot of ups and downs?
*
Yes
No
7) Do you sometimes feel like you're not even yourself or that you're evil?
*
Yes
No
8) Have you ever been so upset that you...
*
told someone you wanted to hurt or kill yourself?
made a suicide attempt, even if it wasn't very serious or you didn't want to die?
I have never attempted or threatened suicide because someone else made me so upset.
9) Do you find yourself acting impulsively at times and in ways that are potentially self-damaging?
*
Yes
No
10) Do you oftentimes feel angry without knowing why?
*
Yes
No
11) Do you tend to get physical and throw things or get into fights?
*
Yes
No
12) Do you give people the cold shoulder and hold grudges for a long time?
*
Yes
No
13)
*
Rate each item by how closely it describes your general demeanor or personality, especially since adulthood:
Excessive fixation with list, rules, details or general organization.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Perfectionist, even to the point of difficulty finishing a task because my standards tend to be so strict.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Excessively devoted to work, even to the detriment of leisure and relationships.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Overconscientious or rigid when it comes to morals, ethics, or values.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Unable to get rid of worthless items, even when their not sentimental.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Reluctant to delegate tasks unless others perform the tasks exactly as asked.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Frugal and maybe less than generous, needing to prepare for potentially more important things or catastrophes.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Generally run short on time, especially leaving most important tasks until the last minute.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Hobbies and activities are great, if done well and according to the rules.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Irritated by others needing to be creative about simple tasks that need to get done, like washing dishing for example.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Stubborn, even when it's in my interest to compromise, it's "the principle that matters".
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Control = calm. Lack of control = panic
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
14) Do you feel somewhat lost when you're alone due to self-doubts or fears about not being able to care for yourself?
*
Yes
No
15) When a close relationship ends, do you feel desperate to quickly find another, even if it might not be the best relationship for you?
*
Yes
No
16) When making decisions:
*
Do you often look for reassurance or advice in every day decisions like what to eat or what clothes to buy?
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Is it difficult for you to make these kinds of decisions on your own?
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Do you tend to end up in situations where someone else is making an important life decision for you (ex. what job to take or who to be friends with)?
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Is it hard for you to express a different opinion with someone you're close to?
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Do you often pretend to agree with someone so he/she won't reject you or dislike you?
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
17) Have others commented to you that...
*
you are a really emotionally expressive person
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
you are too dramatic
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
your emotions seem shallow, or maybe not very sincere
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
you are "flirty" or "inviting", or people often misinterpreted your behavior as such
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
18) Are you pretty good at getting people to do what you want?
*
Yes
No
19) Is it hard for you to really understand what someone else is going through?
*
Yes
No
20) Have other people complained that you aren't very sympathetic to their problems?
*
Yes
No
21) Do you often feel hurt because people don't give you the praise and admiration you feel you deserve?
*
Yes
No
22) Have people told you that you have too high an opinion of yourself?
*
Yes
No
THANK YOU!!