Mood Disorder

1
Patient Name* This field is required.
First Name
Last Name
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UniqueID* This field is required.
3
Email
example@example.com
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Has there ever been a period of time when you were not your usual self and...
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... you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble?* This field is required.
YES
NO
6
... you were so irritable that you shouted at people or started fights or arguments?* This field is required.
YES
NO
7
... you felt much more self-confident than usual?* This field is required.
YES
NO
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... you got much less sleep than usual and found you didn’t really miss it?* This field is required.
YES
NO
9
... you were much more talkative or spoke faster than usual?* This field is required.
YES
NO
10
... thoughts raced through your head or you couldn’t slow your mind down?* This field is required.
YES
NO
11
... you were so easily distracted by things around you that you had trouble concentrating or staying on track? * This field is required.
YES
NO
12
... you had much more energy than usual? * This field is required.
YES
NO
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... you were much more active or did many more things than usual?* This field is required.
YES
NO
14
... you were much more social or outgoing than usual?* This field is required.
YES
NO
15
... you were much more interested in sex than usual?* This field is required.
YES
NO
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... you did things that were unusual for you?* This field is required.
YES
NO
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... spending money got you or your family in trouble?* This field is required.
YES
NO
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Score
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How much of a problem did any of these cause you — like being able to work; having family, money, or legal troubles; getting into arguments or fights?* This field is required.
No Problem
Minor Problem
Moderate Problem
Serious Problem
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Quality Score
21
Do you have any blood relatives with the diagnosis of manic-depressive illness or bipolar disorder?
YESNO
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Have you ever been told by a healthcare professional that you have manic-depressive illness or bipolar disorder?
YESNO
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Empiric Score
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Further medical assessment for bipolar disorder is clearly warranted.
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Today's Provider* This field is required.
Please Select
Please Select
Guy M. Lerner, MD
Leslie Dally, DO
Don Zinno, APRN
Brooke Bischoff APRN, PMHNP
Craig Rouben, APRN
Tara O'Brien, APRN
Monica Taylor, APRN, PMHNP
Brandi Thomas, APRN, PMHNP
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Test
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Date
Date
Month
Day
Year
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Grading
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ALERT
Should be Empty: