Mood Disorder Questionnaire

Patient Information

Patient First Name

Patient Last Name

Email Address*

Instructions: This questionnaire asks about experiences you may have had during periods when you were not your usual self. Please answer each question honestly based on your experiences.

1. Has there ever been a period of time when you were not your usual self and...

...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?

Yes No

...you were so irritable that you shouted at people or started fights or arguments?

Yes No

...you felt much more self-confident than usual?

Yes No

...you got much less sleep than usual and found you didn't really miss it?

Yes No

...you were much more talkative or spoke much faster than usual?

Yes No

...thoughts raced through your head or you couldn't slow your mind down?

Yes No

...you were so easily distracted by things around you that you had trouble concentrating or staying on track?

Yes No

...you had much more energy than usual?

Yes No

...you were much more active or did many more things than usual?

Yes No

...you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night?

Yes No

...you were much more interested in sex than usual?

Yes No

...you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?

Yes No

...spending money got you or your family into trouble?

Yes No

Additional Questions

2. 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

3. How much of a problem did any of these cause you - like being unable to work; having family, money or legal troubles; getting into arguments or fights?

No Problem Minor Problem Moderate Problem Serious Problem

4. Have any of your blood relatives (i.e., children, siblings, parents, grandparents, aunts, uncles) had manic-depressive illness or bipolar disorder?

Yes No

5. Has a health professional ever told you that you have manic-depressive illness or bipolar disorder?

Yes No

Thank You!

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