Violence and Sexual Assault
- Sexual assault victim
- Victim of any sexual assault
- Attempted penetration
- Actually penetrated
- Unwanted sexual force, threat, incapacitation
- Struck or injured by another (as victim)
- Struck or injured another (as perpetrator)
Specific Self Harm Behavior
- Attempted suicide
- Made a plan for attempting suicide
- Thought about attempting suicide
- Carved words or symbols into skin
- Burned self
- Cut self
- Punched or banged self
- Punched or banged an object to hurt self
- Rubbed sharp objects into skin
- Scratched self
- Bit self
- Pulled ones' hair
- Interfered with a wound healing
Personal Details
- Transgender status
- Sexual Orientation
- Religious views
- Parents' financial situation
- Body self-image (overweight / underweight)
Specific Medical Diagnosis
- Schizophrenia
- Schizo-affective disorder
- Bipolar/manic depression
- Psychosis
- Brief psychotic disorder
- Delusional disorder
- Schizophrenia disorder
- Shared psychotic disorder
- Post traumatic stress disorder (PTSD)
- Dysthymia (chronic depression)
- Cyclothymia (can be thought of as low-level bipolar disorder)
- Antisocial personality disorder
- Avoidant personality disorder
- Borderline personality disorder
- Dependent personality disorder
- Histrionic personality disorder
- Narcissistic personality disorder
- Obsessive-compulsive disorder
- Paranoid personality disorder
- Schizoid personality disorder
- Schizotypal personality disorder
- Depression
- Anxiety
- Obsessive-compulsive disorder
- Acute stress disorder
- Attention Deficit Disorder
- Eating Disorder
- Substance Abuse
- Major depressive disorder
- Panic disorder
- Social phobia
- Attention deficit hyperactivity disorder (ADHD or ADD)
- Learning Disability
- Bulimia
- Binge-eating disorder
- Alcohol abuse or other alcohol-related disorders
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Specific Drug Use
- Heroin
- Cocaine (crack, coke)
- Amphetamines (Adderall, Ritalin, methamphetamines, crystal meth, speed, uppers, ups)
- LSD
- Ecstasy (MDMA)
- Other psychedelics or hallucinogens like mushrooms, mescaline or PCP
- Club drugs (Special K, Super K, Ketamine, Liquid G, GHB)
- Marijuana/cannabis (hashish, blunts)
- Synthetic marijuana/cannabis (or Spice, K2)
- Barbiturates or sedatives (prescription-type sleeping pills like Seconal, Ambien, Nembutal, downs or Yellow Jackets)
- Tranquilizers (prescription-type drugs like Valium, Librium, Xanax, Ativan, Klonopin)
- Pain relievers/ other opiate-type prescription drugs (codeine, morphine, Demerol, Percodan, Percocet, Vicodin, Oxycontin/oxycodon)
Prescription Medication Use: Past & Present
- Psychostimulants (e.g., methylphenidate (Ritalin, or Concerta), amphetamine salts (Adderall), dextroamphetamine (Dexedrine), etc.)
- Antidepressants (e.g., fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), escitalopram (Lexapro), venlafaxine (Effexor), buproprion (Wellbutrin), etc.)
- Anti-psychotics (e.g., haloperidol (Haldol), clozapine (Clozaril), risperidone (Risperdal), olanzapine (Zyprexa), etc.)
- Anti-anxiety medications (e.g., lorazepam (Ativan), clonazepam (Klonopin), alprazolam (Xanax), buspirone (BuSpar), etc.)
- Mood stabilizers (e.g., lithium, valproate (Depakote), lamotrigine (Lamictal), carbamazapine (Tegretol), etc.)
- Sleep medications (e.g., zolpidem (Ambien), zaleplon (Sonata), etc.)
- Use of medication(s) without a prescription
Drinking, Sex, Gambling
- Number of recent sex partners
- Heavy drinking (four or more, five or more)
- Gambling (sports betting, cards for money, online, lottery, pool, slots, horses)
Use of Mental Health Services: Past & Present
- Number of visits in last year
- Identity of Mental Health Service Provider
- MIT Medical
- iREFS (for graduate students), Medlinks (for undergraduate students)
- Psychiatric Emergency Services/Psych Emergency Room (ER)
- Inpatient psychiatric hospital
- Partial hospitalization program
- Provider in the local community (not on campus)
- Provider in another location (such as your hometown)
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