THE MOOD DISORDER QUESTIONNAIRE

THE MOOD DISORDER QUESTIONNAIREdelivered through

Name *

First

Last

Date of birth

Today's Date

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

Please answer the questions below.

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

YES
NO

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

YES
NO

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

YES
NO

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

YES
NO

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

YES
NO

7. you were so easily distracted by things around you that you had trouble concentrating

YES
NO

8. you had much more energy than usual?

YES
NO

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

YES
NO

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

YES
NO

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

YES
NO

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

YES
NO

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

YES
NO

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 unable to work; having family, money, or legal troubles; getting into arguments or fights? Please choose one response only

No Problem
Minor Problem
Moderate Problem
Serious Problem

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

YES
NO

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

YES
NO