Bipolar Questionnaire

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Bipolar Questionnaire

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Demographics

I am:

Male Female

Age:

1. Have you ever noticed that your mood and/or energy level shifts drastically from time to time and that sometimes you are sad and 'down' with a low energy level and at other times very high?

Yes No

2. Do you have periods of 'normal' mood in between the 'lows' and 'highs' where your mood and energy level feels 'right' and you are functioning well and then notice a marked shift or 'switch' in the way you feel?

Yes No

3. Have you had a 'low' phase where you felt a lack of energy, stayed in bed or got extra sleep, and had little or no motivation to do things you needed to do?

Yes No

4. If you had this 'low' or 'down' phase, did you feel 'blue,' sad all the time, or depressed, maybe even helpless or suicidal?

Yes No

5. During a 'low' period, was it difficult for you to function at work, home or socially?

Yes No

6. Has there ever been a period of time when you felt so good or so hyper that other people thought you were not your normal self?

Yes No

7. Have you ever felt that you were not your usual self and you were so 'high' or hyper that you got into trouble?

Yes No

8. Has there ever been a period of time when you felt that you were not your usual self and you were so irritable that you shouted at people or started fights or arguments for little or no reason?

Yes No

9. Have you had a period of time where you felt much more self-confident than usual, like you could do anything in the world?

Yes No

10. Have you had a period of time where you felt that you were not your usual self and you got much less sleep than usual and found you didn't really miss it and were not tired the next day?

Yes No

11. Have you had a period of time where you were much more talkative or spoke much faster than usual and people had difficulty following what you were saying?

Yes No

12. Has there ever been a period of time when you felt that you were not your usual self and thoughts raced through your head or you felt you couldn't slow your mind down?

Yes No

13. Has there ever been a period of time when you felt that you were not your usual self and you were so easily distracted by things around you that you had trouble concentrating or staying on track?

Yes No

14. Has there ever been a period of time when you had much more energy than usual, were much more active or did many more things than usual?

Yes No

15. Has there ever been a period of time when you felt that you were not your usual self and you were much more social or outgoing than usual, for example, giving parties or telephoning friends in the middle of the night?

Yes No

16. Has there ever been a period of time when you felt that you were not your usual self and you were much more interested in sex than usual?

Yes No

17. Has there ever been a period of time when you felt that you were not your usual self and you did things that were unusual for you or that other people thought were excessive, foolish, or risky?

Yes No

18. Has there ever been a period of time when you felt that you were not your usual self and you spent a lot of money that got you or your family into trouble?

Yes No

19. Have any of the things you have done during a period of not feeling like yourself caused problems with work or family or gotten you into legal troubles, arguments or fights?

Yes No

20. Have any of your blood relatives (i.e. brothers or sisters, parents, grandparents, aunts, uncles or children) had manic-depressive illness or bipolar disorder?

Yes No

21. Has a doctor, nurse, counselor or other health professional ever told you that you have manic-depressive illness or bipolar disorder?

Yes No

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