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1901 North Olden Avenue Ext, Suite 11A, Ewing, NJ 08618
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[email protected]
1901 North Olden Avenue Ext, Suite 11A, Ewing, NJ 08618
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Mood Disorder Questionnaire Screener
MOOD DISORDER QUESTIONNAIRE SCREENER
Name
First
Date
MM slash DD slash YYYY
Please answer each question as best you can.
Instructions: Check the answer that best applies to you.
1. HAS THERE EVER BEEN A PERIOD OF TIME WHEN YOU WERE NOT YOUR USUAL SELF AND 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
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
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
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
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
HAS THERE EVER BEEN A PERIOD OF TIME WHEN YOU WERE NOT YOUR USUAL SELF AND YOU THOUGHTS RACED THROUGH YOUR HEAD OR YOU COUDN\'T SLOW YOUR MIND DOWN?
Yes
No
HAS THERE EVER BEEN A PERIOD OF TIME WHEN YOU WERE NOT YOUR USUAL SELF AND YOU WERE EASILY GET DISTRUCTED BY THINGS AROUND YOU THAT YOU HAD TROUBLE CONCENTRATING OR STAYING ON TRACK?
Yes
No
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
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 FREINDS IN THE MIDDLE OF THE NIGHT?
Yes
No
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
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
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 EXESSIVE, FOOLISH OR RISKY?
Yes
No
HAS THERE EVER BEEN A PERIOD OF TIME WHEN YOU WERE NOT YOUR USUAL SELF AND SPENDING MONEY GOT YOU ON YOUR FAMILY IN TROUBLE?
Yes
No
2. IF YOU CHECK YES TO MORE THAN ONE OF THE ABOVE , HAVE SEVERAL OF THESE HAPPENED DURING THE SAME PERIOD OF TIME? PLEASE CHECK 1 RESPONSE ONLY.
Yes
No
3.HOW MUCH OF A PROBLEM DID ANY OF THESE CAUSE YOU - LIKE BEING ABLE TO WORK ; HAVING FAMILY, MONEY, OR LEGAL TROUBLES ; GETTING INTO ARGUEMENTS OR FIGHTS ? PLEASE CHECK ONE RESPONSE ONLY.
No Problem
Minor Problem
Moderate Problem
Serious Problem
4.HAVE ANY OF YOUR BLOOD RELATIVES (IE, CHILDREN, SIBLINGS, PARENTS, GRANDPARENTS, AUNTS, UNCLES) HAD MANIC DEPRESSION ILLNESS OR BIPOLAR DISORDER?
Yes
No
5. HAS A HEALTH PROFESIONAL EVER TOLD YOU THAT YOU HAVE A MANIC-DEPRESSIVE ILLNESS OR BIPOLAR DISORDER?
Yes
No
THE QUISTIONNAIRE SHOULD BE USED AS A STARTING POINT. IT IS NOT A SUBTITLE FOR A FULL MEDICAL EVALUATION . BIPOLAR DISORDER IS A COMPLEX ILLNESS , AND AN ACCURATE , THOROUGH DIAGNOSTICS CAN ONLY BE MADE THOUR A PERSONAL EVALUATION BY YOUR DOCTOR,
MQ-36188 3000129717 THIS INSTRUMENT IS DESIGNED FOR SCREENING PURPOSE ONLY AND IT'S NOT TO BE USED AS ADIAGNOSTIC TOOLS
HOW TO USE
THE QUISTIONNAIRE TAKES LESS THAN 6 MINUTES TO COMPLETE. PATIENT SIMPLY CHECK THE YES OR NO BOXES IN RESPONSE TO THE QUESTIONS. THE LAST QUESTIONS RETAINS TO THE PATIENT LEVEL OF FUNCTIONAL IMPAIREMENT , THE PHYSICIAN, NURSE, OR MEDICAL STUFF ASSISTANT THEN SCORES THE COMPLETED QUESTIONAIRE.
HOW TO SCORE
FURTHER MEDICAL ASSESSMENT FOR BIPOLAR DISORDER IS CLEARLY WARRANTED IF PATIENT
Answer Yes to 7 or more of the events in question #1 AND
Answer Yes to question #2 AND
Answer Moderate problem or Serious problem to question #3
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