Name Date Instructions Check the answer that best applies to you Please answer each question as best you can Has there ever been a period of time when you were not your usual self andÉ쥹ou ID: 937877
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Mood Disorder Questionnaire Name: Date: Instructions: Check ( )the answer that best applies to you. Please answer each question as best you can. Has there ever been a period of time when you were not your usual self andÉ쥹ou 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? 쥹ou were so irritable that you shouted at people or started fights or arguments? 쥹ou felt much more self-confident than usual? 쥹ou got much less sleep than usual and found you didnÕt really miss it? 쥹ou were much more talkative or spoke faster than usual? Éthoughts raced through your head or you couldnÕt slow your mind down?쥹ou were so easily distracted by things around you that you had trouble concentrating or staying on track? active or did many more things than usual?쥹ou were much more social or outgoing than usual, for example, you telephoned friends in the middleof the night? ested in sex than usual?you did things that were unusual for you or that other people might have ere excessive, foolish, or risky? Éspending money got you or your family in trouble? If you checked YES to more than one of the above, have several of these ever Please check 1 response only. How
much of a problem did any of these cause you Ñ like being able to work; arguments or fights? Please check 1 response only. No problemMinor problem Moderate problemSerious problem aunts, uncles) had manic-depressive illness or bipolar disorder? Has a health professional ever told you that you have manic-depressive illness or bipolar disorder? arting point. It is not a substitute for a full medical evaluation.Bipolar disorder is a complex illness, and an accurate, thorough diagnosis can only be made through personal evaluation by your doctor. eening instrument for bipolar spectrum Am J Psychiatry. YesNo MQ-36188 3000129717 This instrument is designed for screening purposes only and is not to be used as a diagnostic tool. How to Use The questionnaire takes less than 5 minutes to complete. Patients simply check the yes or noboxes in response to thequestions. The lastquestion pertains to the patientÕs level offunctional impairment. The physician, nurse, or medicalstaff assistant then scores thecompleted questionnaire. How to Score Further medical assessment for bipolardisorder is clearly warranted if patient: Answers to 7 or more of the events in question #1 Answers to question #2 Answers Moderate problem problem to question #3