Mood Disorder Questionnaire Screener Form

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

Has there ever been a period of time when you were not your usual self and you you were so irritable that you shouted at people or started fights or arguments?

Yes

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

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

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

Has there ever been a period of time when you were not your usual self and you thoughts raced through your head or you couldn’t slow your mind down?

Yes

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

Has there ever been a period of time when you were not your usual self and you had much more energy than usual?

Yes

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

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

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

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

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

2.If you checked YES to more than one of the above, have several of these ever happened during the same period of time? Please check 1 response only. *

Yes

3.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? Please check 1 response only.

No Problem	Minor Problem
Moderate Problem	Serious Problem

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

Yes

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

Yes

This questionnaire should be used as a starting 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 a personal evaluation by your doctor.

MQ-36188 3000129717This instrument is designed for screening purposes only and is not to be used as a diagnostic tool.

How to UseThe questionnaire takes less than 5 minutes to complete.Patients simply check the yes or noboxes in response to the questions. The lastquestion pertains to the patient’s level offunctional impairment. The physician, nurse, or medical staff assistant then scores thecompleted questionnaire.

How to ScoreFurther medical assessment for bipolardisorder is clearly warranted if patient: