Mood Disorder Questionnaire Mood Disorder Questionnaire * Input based on your choices: Yes, No First Name Last Name Phone (###) ### #### Email * What triggers your mood swings? * 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 2. Has there ever been a period of time when you were not your usual self and you were so irritable that you shouted at people or started fights or arguments? Yes No 3. Has there ever been a period of time when you were not your usual self and you felt much more self-confident than usual? Yes No 4. Has there ever been a period of time when you were not your usual self and you got much less sleep than usual and found you didn’t really miss it? Yes No 5. Has there ever been a period of time when you were not your usual self and you were much more talkative or spoke faster than usual? Yes No 6. Has there ever been a period of time when you were not your usual self and thoughts raced through your head or you couldn’t slow your mind down? Yes No 7. Has there ever been a period of time when you were not your usual self and you were so easily distracted by things around you that you had trouble concentrating or staying on track? Yes No 8. Has there ever been a period of time when you were not your usual self and you had much more energy than usual? Yes No 9. Has there ever been a period of time when you were not your usual self and you were much more active or did many more things than usual? Yes No 10. Has there ever been a period of time when you were not your usual self and you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night? Yes No 11. Has there ever been a period of time when you were not your usual self and you were much more interested in sex than usual? Yes No 12. Has there ever been a period of time when you were not your usual self and you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky? Yes No 13. Has there ever been a period of time when you were not your usual self and spending money got you or your family in trouble? Yes No 14. 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 15. 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 16. Have any of your blood relatives (ie, children, siblings, parents, grandparents, aunts, uncles) had manic-depressive illness or bipolar disorder? Yes No 17. Has a health professional ever told you that you have manic-depressive illness or bipolar disorder? Yes No Thank you!
