“Successful Living With Illness” Questionnaire

Are you living with a medical illness? How are you doing? It’s hard enough to have a medical illness, but if you’re having trouble coping with it, things can be even more difficult.

This questionnaire can help you determine which aspect, if any, you might like to improve in your efforts to live successfully with an illness. It can help you determine what you may want to prioritize in your self-improvement efforts.

Complete the following “Successful Living With Illness” Questionnaire. After clicking the “submit” button, you’ll learn your score, as well some valuable information that can help you to live a better life, despite your illness.

DIRECTIONS: Answer each of these questions as honestly and accurately as you possibly can. (Consider the time-frame of the past month.) Answer quickly with the first answer that comes into your mind by clicking on the most appropriate circle.

Please click one circle for each of the 20 items:

1. How often are physical symptoms interfering with your life?
2. Are you experiencing any job or school-related problems?
3. Are you experiencing financial problems?
4. Are your social relationships affected by the illness?
5. Is sleep a problem for you because of your illness??
6. Are you happy with your family relationships?
7. Do you think negative thoughts because of your illness?
8. Are you depressed because of your illness??
9. Do you have a good relationship with your doctor(s)?
10. How much do you like yourself?
11. Are you satisfied with the activities that you are able to do?
12. Do you feel "stressed out" because of your illness??
13. Are you comfortable with the illness treatment program?
14. Are you angry because of your illness??
15. Are you fearful or anxious because of your illness??
16. Does it bother you what people say about the illness?
17. Are you able to “talk things out” with someone who is supportive?
18. Do you worry about the illness or its impact?
19. Do you use drugs or alcohol more than you should?
20. Are you hopeful about the future?

Please complete these boxes to obtain your results.

Name
Email
Phone Number
Age

How Can We Help?

Many people from all over the world have benefited from the successful, strategy-packed mental health services offered by The Coping Counselors at the Center for Coping. You can, too!

  • If you have questions about any of the issues you are dealing with, why not set up a free, no-obligation consultation with one of our Coping Counselors?
  • Simply call us at (516) 822-3131, with any questions or to set up your free appointment.
  • Or e-mail us at info@coping.com. We’ll be happy to respond to your e-mail.
  • Sign up for our free, email newsletter, “E-Cope.” See below.

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