Mood Disorder Questionnaire
Patient Name
First Name
Last Name
Patient Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Has there ever been a period of time when you were not your usual self and…
*
Rows
Yes
No
…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?
…you were so irritable that you shouted at people or started fights or arguments?
…you felt much more self-confident than usual?
…you got much less sleep than usual and found you didn’t really miss it?
…you were much more talkative or spoke faster than usual?
…thoughts raced through your head or you couldn’t slow your mind down?
…you were so easily distracted by things around you that you had trouble concentrating or staying on track?
…you had much more energy than usual?
…you were much more active or did many more things than usual?
…you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night?
…you were much more interested in sex than usual?
…you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?
…spending money got you or your family in trouble?
If you checked YES to more than one of the above, have several of these ever happened during the same period of time?
Yes
No
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?
No Problem
Minor Problem
Moderate Problem
Serious Problem
Have any of your blood relatives (ie, children, siblings, parents, grandparents,aunts, uncles) had manic-depressive illness or bipolar disorder?
Yes
No
Has a health professional ever told you that you have manic-depressive illnessor bipolar disorder?
Yes
No
Number of Questions answered yes.
Submit
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