Personal Information
Name: ___________________________
Phone: ___________________________
Instructions
Has there ever been a period of time when you were not your usual self and…
Please answer Yes or No to each question.
Questions
- …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 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 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 - …you were much more active or did many more things than usual?
☐ Yes ☐ No
Scoring
- Yes = 1 point
- No = 0 points
Total Points: __________
Results Interpretation
0–4 Points
Little or No Indication of Mood Disorders
Your answers suggest that there is little or no indication that you are experiencing symptoms common among people with mood disorders. However, this questionnaire is not a substitute for a proper diagnosis from a health care professional. It is recommended that you schedule an appointment with your doctor or a mental health professional to address any concerns.
5–9 Points
Moderate Indication of Mood Disorders
Your answers suggest a moderate indication that you are experiencing symptoms common among people with mood disorders. However, this questionnaire is not a substitute for a proper diagnosis from a health care professional. It is recommended that you schedule an appointment with your doctor or a mental health professional to address any concerns.
Additional Information (From Original Document)
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