Resources

Mood Disorder Questionnaire

Instructions: Please answer each question as best you can. Upon completing this form, you will be able to print your completed form and take it to your health care practitioner. Click here for more info on the Mood Disorder Questionnaire.

Note: This questionnaire is completely anonymous and the results are not stored.

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
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