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Grassroot Psychiatry Mental Health Clinic
Take care of your health and happiness with us
Primary Menu
Home
About
Team
Services
Anxieties
Depression
Panic Attacks
ADHD
Psychosis
PTSD
Addictions
Substance Abuse
Bipolar Disorders
Mood Disorders
Schizophrenia
ODD & DSDM
Policies
Forms
Contact
Mood Disorders Questionnaire
Patient Name
*
Phone Number
*
Email Address
*
normal self or you were so hyper that you got into trouble?
Yes
No
02. 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
03. 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
04. 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
05. 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
06. 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
07. 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
08. 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
09. 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
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