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Ewing Mental Health LLC

Mood Disorder Questionnaire Screener

Name
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?
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?
HAS THERE EVER BEEN A PERIOD OF TIME WHEN YOU WERE NOT YOUR USUAL SELF AND YOU FELT MUCH MORE SELF -CONFIDENT THAN USUAL?
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?
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?
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?
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?
HAS THERE EVER BEEN A PERIOD OF TIME WHEN YOU WERE NOT YOUR USUAL SELF AND YOU HAD MUCH MORE ENERGY THAN USUAL?
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?
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?
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?
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?
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?
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.
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.
4.HAVE ANY OF YOUR BLOOD RELATIVES (IE, CHILDREN, SIBLINGS, PARENTS, GRANDPARENTS, AUNTS, UNCLES) HAD MANIC DEPRESSION ILLNESS OR BIPOLAR DISORDER?
5. HAS A HEALTH PROFESIONAL EVER TOLD YOU THAT YOU HAVE A MANIC-DEPRESSIVE ILLNESS OR BIPOLAR DISORDER?
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