Mood Disorder Screening

Name Name * First Last
Account Number *

Has there ever been a period of time when you were not your usual self and...
	Yes	No
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?	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	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?No
you were so irritable that you shouted at people or started fights or arguments?	you were so irritable that you shouted at people or started fights or arguments?Yes	you were so irritable that you shouted at people or started fights or arguments?No
you felt much more self-confident than usual?	you felt much more self-confident than usual?Yes	you felt much more self-confident than usual?No
you got much less sleep than usual and found you didn't really miss it?	you got much less sleep than usual and found you didn't really miss it?Yes	you got much less sleep than usual and found you didn't really miss it?No
you were much more talkative or spoke faster than usual?	you were much more talkative or spoke faster than usual?Yes	you were much more talkative or spoke faster than usual?No
thoughts raced through your head or you couldn't slow your mind down?	thoughts raced through your head or you couldn't slow your mind down?Yes	thoughts raced through your head or you couldn't slow your mind down?No
you were so easily distracted by things around you that you had trouble concentrating or staying on track?	you were so easily distracted by things around you that you had trouble concentrating or staying on track?Yes	you were so easily distracted by things around you that you had trouble concentrating or staying on track?No
you had much more energy than usual?	you had much more energy than usual?Yes	you had much more energy than usual?No
you were much more active or did many more things than usual?	you were much more active or did many more things than usual?Yes	you were much more active or did many more things than usual?No
you were much more social or outgoing than usual; for example, you telephoned friends in the middle of the night?	you were much more social or outgoing than usual; for example, you telephoned friends in the middle of the night?Yes	you were much more social or outgoing than usual; for example, you telephoned friends in the middle of the night?No
you were much more interested in sex than usual?	you were much more interested in sex than usual?Yes	you were much more interested in sex than usual?No
you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?	you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?Yes	you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?No
spending money got you or your family into trouble?	spending money got you or your family into trouble?Yes	spending money got you or your family into trouble?No

If you checked YES to more than one of the above, have several of these ever happened during at least a four day period of time?

If you checked YES to more than one of the above, have several of these ever happened during at least a four day 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?

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

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