The Neurotransmitter (Online Publication)
Surveys
Body Dysmorphic Disorder BDD Survey
Obsessive Compulsive Disorder OCD Survey
Books Written By Our Staff Members
Public Speaking
Staff members are available to speak for local community organizations such as women's groups, clubs, professional groups and schools.
Foreign Languages
For non-English speaking patients, we have staff members who are fluent in various languages such as Spanish, Italian, Japanese, Malayalam, Tamil, Portuguese and Turkish.

Conservative use of drug therapy
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A psychological approach that emphasizes the present and future of the patient, rather than the past.
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Emphasis on nutrition and physical exercise
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Family participation, if appropriate
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Psychoeducation for patients and relatives
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Body Dysmorphic Demographics Form
  
Name:
DOB:
Marital Status:
Current Employment:
Employment History - please list job titles and years employed:
Education:
1. List the aspects of your appearance that cause you distress (Name the body parts and what aspect of those body parts bothers you)
A. What do you do about it?
Mirror check
Avoid Mirrors
Camouflage
Use Beauty products		 Avoid crowded places
Wear certain clothes
Other
B. Do you think people are talking about you? 
C. Do you think people are looking at you? 
2. Age when your BDD symptoms began
3. Please list any other disorders you have/had and the age they began

4. Please list the type and duration of any treatment you have received for your BDD (hypnosis, behavior therapy, cognitive therapy, psychoanalysis)
5. Please list the medication you have been on for your BDD in the past (indicate dosages if known)
6. Please list the medication you are currently on for your BDD (indicate dosages if known)
7. Please list the number of hospitalizations and duration of each hospitalization for your BDD or any other difficulty (please indicate reason for hospitalization if other than BDD)
8. List any family members who have had psychiatric problems and indicate problem (Ex: mother/obsessive compulsive disorder, grandfather/major depression)
D. Response of family members to your symptoms:
9. Please list any previous suicide attempts (include dates)
10. Have you ever had plastic surgery?  
If yes, please indicate date and type of plastic surgery performed
11. Were you satisfied with the results of the surgery at that time? 
12. Are you still satisfied with the results of the surgery at this time?
13. Have you ever seen the following medical professionals for concerns about your appearance? (please select all that apply)
Dematologist Endocrinologist Electrolysis Specialist
Nutrition Counseling Other
14. If yes, how many times a year do you see these professionals?
15. The following are a list of common life experience and events that may affect your condition. Please read the following items and indicate if your symptoms improved, do not change, or worsened during each life event by circling the appropriate choice.
During pregnancy Does not apply -or-
After delivery Does not apply -or-
Beginning menstruation  Does not apply -or-
Change in residence Does not apply -or-
Change in schools Does not apply -or-
Being teased by peers about your appearance Does not apply -or-
Criticism about appearance by family members Does not apply -or-
Academic difficulties Does not apply -or-
Accident
(please specify type)		 Does not apply -or-
Sports Injury Does not apply -or-
Medical/Health problems Does not apply -or-
(please specify type)
Medical/health problems of a family member Does not apply -or-
Marriage Does not apply -or-
Divorce  Does not apply -or-
Marital separation Does not apply -or-
Difficulties with interpersonal relationships Does not apply -or-
Death of spouse Does not apply -or-
Loss of job Does not apply -or-
Difficulties at job Does not apply -or-
Retirement Does not apply -or-
Sexual difficulties Does not apply -or-
Change in financial state Does not apply -or-
Death of close friend Does not apply -or-
Death of a family member Does not apply -or-
Religious or spiritual difficulties Does not apply -or-
Minor violations of the law Does not apply -or-
Change in social activities Does not apply -or-
Other (Please Specify)
16. Were you ever teased or criticized by others about your appearance? 
If yes, please describe the experience (Who teased you, what specifically were you teased about, how long were you teased for?)
PLEASE NOTE the definitions of abuse, at the end of this form, before answering the proceeding questions
17. Do you have any history of sexual, emotional, physical abuse, or neglect? (If yes, please answer the following questions. If no, please skip to question #31)
18. Please select all of the following that apply to you:
  
Physical Abuse Emotional Abuse Sexual Abuse Neglect 
The following questions relate to PHYSICAL abuse:
19. Please list age at which your PHYSICAL abuse began and how long it lasted
20. Who physically abused you? (Father, stranger, aunt, family friend etc.)
21. Please describe the details regarding the physical abuse
The following questions relate to SEXUAL abuse:
22. Please list age at which your SEXUAL abuse began and how long it lasted
23. Who sexually abused you? (Father, stranger, aunt, family friend etc.)
24. Please describe the details regarding the SEXUAL abuse
The following questions relate to Emotional abuse:
25. Please list age at which your EMOTIONAL abuse began and how long it lasted
26. Who emotionally abused you? (Father, stranger, aunt, family friend etc.)
27. Please describe the details regarding the EMOTIONAL abuse
The following questions relate to NEGLECT:
28. Please list age at which you experienced neglect and how long it lasted
29. Who neglected you? (Father, mother, legal guardian)
30. Please describe the details regarding the NEGLECT

E. Please describe any other significant trauma you may have experienced in the past and at what age did it occur (e.g. car accident):
31. How much time in a day do you spend on thoughts about your defects in appearance in total? Select the appropriate one
32. How much time in a day do you spend on all activities related to concerns about your appearance in total (such as looking at defect in the mirror, applying make-up or using clothing to cover the defect, asking others about your appearance, touching your defect etc.)?
33. How do you rate your overall attractiveness as compared to the rest of the population?
For the next three questions, please consider the three most distressing defects SEPARATELY
34. How do you rate your body part of concern as compared to the rest of the population?
Name body part

   
35. How do you rate your body part of concern as compared to the rest of the population?
Name body part

  
36. How do you rate your body part of concern as compared to the rest of the population?
Name body part

  
Would you like IBBTR to contact you with further information on BDD? If so, please submit your e-mail address or phone number:
E-Mail -
Home Phone



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