mooddis

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Screening for
Mood Disorder

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


                              Part One

1. Has there ever been a period of time when you were not your usual self and…

…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 were so irritable that you shouted at people or started fights or arguments?

…you felt much more self-confident than usual?

…you got much less sleep than usual and found you didn’t really miss it?

…you were much more talkative or spoke much faster than usual?

…thoughts raced through your head or you couldn’t slow your mind down?

…you were so easily distracted by things around you that you had trouble concentrating or staying
on track?

…you had much more energy than usual?

…you were much more active or did many more things than usual?

…you were much more social or outgoing than usual—for example, you telephoned friends in the
middle of the night?

…you were much more interested in sex than usual?

…you did things that were unusual for you or that other people might have thought were excessive,
foolish, or risky?

…spending money got you or your family into trouble?

                                  Part Two

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

                                 Part Three

3. 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

No problem

Minor problem

Moderate problem

Serious problem

Finished!

When finished, print this page to discuss the results of this
questionnaire with Dr. Wang.

*Adapted from Hirshfeld RMA, et al. Am J Psychiatry. 2000;157:1873-1875.