Bio-Behavioral Institute

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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OCD Demographics Form

Name:

DOB:

Marital Status:

Current Employment:

Employment History - please list job titles and years employed:

Education:

1. Age when your OCD symptoms began

2. Please list any other disorders you have/had and the age they began

3. Please list the type and duration of any treatment you have received for your OCD (hypnosis, behavior therapy, cognitive therapy, psychoanalysis)

4. Please list the medication you have been on for your OCD in the past (indicate dosages if known)

5. Please list the medication you are currently on for your ODD (indicate dosages if known)

6. Please list the number of hospitalizations and duration of each hospitalization for your OCD or any other difficulty (please indicate reason for hospitalization if other than OCD)

7. List any family members who have had psychiatric problems and indicate problem (Ex: mother/obsessive compulsive disorder, grandfather/major depression)

A. Response of family members to your symptoms:

8. Please list any previous suicide attempts (include dates)

9. 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 (please specify type)	Does not apply -or-

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

10. 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)

11. Please select all of the following that apply to you:

Physical Abuse Emotional Abuse Sexual Abuse Neglect

The following questions relate to PHYSICAL abuse:

12. Please list age at which your PHYSICAL abuse began and how long it lasted

13. Who physically abused you? (Father, stranger, aunt, family friend etc.)

14. Please describe the details regarding the physical abuse

The following questions relate to SEXUAL abuse:

15. Please list age at which your SEXUAL abuse began and how long it lasted

16. Who sexually abused you? (Father, stranger, aunt, family friend etc.)

17. Please describe the details regarding the SEXUAL abuse

The following questions relate to EMOTIONAL abuse:

18. Please list age at which your EMOTIONAL abuse began and how long it lasted

19. Who emotionally abused you? (Father, stranger, aunt, family friend etc.)

20. Please describe the details regarding the EMOTIONAL abuse

The following questions relate to NEGLECT:

21. Please list age at which you experienced neglect and how long it lasted

22. Who neglected you? (Father, mother, legal guardian)

23. Please describe the details regarding the NEGLECT

B. Please describe any other signficant trauma you may have experienced in the past and at what age did it occur (e.g. car accident):

24. How much time in a day do you spend on obsessive thoughts in total? Select the appropriate one

25. How much time in a day do you spend performing rituals in total (such as handwashing, checking, repeating)?

26. Is there an aspect of your physical appearance that you are not satisfied with? (Such as unsymmetrical breasts, balding hair, large nose, etc.) If yes, please describe your concerns

27. 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

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

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

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

Would you like the Bio-Behavioral Institute to contact you with further information on OCD? If so, please submit your e-mail address or phone number:

E-Mail -
Home Phone