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Screening for Mood Disorder

Instructions for patients: Please check ONE BOX ONLY for each of the questions below.

PART ONE:

Has there ever been a period of time when you were not yourself and...

1. ...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
2. ...you were so irritable that you shouted at people or started fights or arguments?

Yes   No
3. ...you felt much more self-confident than usual?

Yes   No
4. ...you got much less sleep than usual and found you didn't really miss it?

Yes   No
5. ...you were much more talkative or spoke much fast then usual?

Yes   No
6. ...thoughts raced through your head or you couldn't slow your mind down?

Yes   No
7. ...you were so easily distracted by things around you that you had trouble concentrating or staying on track?

Yes   No
8. ...you had much more energy than usual?

Yes   No
9. ...you were much more active or did many more things than usual?

Yes   No
10. ...you were much more social or outgoing than usualfor example, you telephoned friends in the middle of the night?

Yes   No
11. ...you were much more interested in sex than usual?

Yes   No
12. ...you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?

Yes   No
13. ...spending money got you or your family into trouble?

Yes   No

If you checked YES to more than one of the questions in Part One, continue to Part Two and Part Three.

PART TWO:

1. Did several of the situations that you said YES to ever happen during the same period of time?

Yes   No

PART THREE:

1. How much of a problem did any of these situations cause you (like being unable to work; having family, money, or legal problems; and/or getting into serious arguments or fights)?

Yes   No

Having more than one illness at the same time can make it difficult to diagnosis and treat the different conditions. Illnesses that sometimes complicate an anxiety disorder include depression and substance abuse. With this in mind, please take a minute to answer the following questions:

1. Have you experienced changes in sleeping or eating habits?

No Problem
Minor Problem
Moderate Problem
Serious Problem  



Please discuss the results of this questionnaire with your physician.

Adapted from Hirschfeld RMA, et al. AM J Psychiatry. 2000; 157: 1873-1875.