Licensed GA Counselor Since 1991

Mood Disorder Questionnaire

Client's Name *

First

Last

Client's Birthday *

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

	Yes	No
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?	Yes1. 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	No1. 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? No
2. You were so irritable that you shouted at people or started fights or arguments?	Yes2. You were so irritable that you shouted at people or started fights or arguments? Yes	No2. You were so irritable that you shouted at people or started fights or arguments? No
3. You felt much more self-confident than usual?	Yes3. You felt much more self-confident than usual? Yes	No3. You felt much more self-confident than usual? No
4. You got much less sleep than usual and found that you didn't really miss it?	Yes4. You got much less sleep than usual and found that you didn't really miss it? Yes	No4. You got much less sleep than usual and found that you didn't really miss it? No
5. You were more talkative or spoke much faster than usual?	Yes5. You were more talkative or spoke much faster than usual? Yes	No5. You were more talkative or spoke much faster than usual? No
6. Thoughts raced through your head or you couldn't slow your mind down?	Yes6. Thoughts raced through your head or you couldn't slow your mind down? Yes	No6. Thoughts raced through your head or you couldn't slow your mind down? No
7. You were so easily distracted by things around you that you had trouble concentrating or staying on track?	Yes7. You were so easily distracted by things around you that you had trouble concentrating or staying on track? Yes	No7. You were so easily distracted by things around you that you had trouble concentrating or staying on track? No
8. You had more energy than usual?	Yes8. You had more energy than usual? Yes	No8. You had more energy than usual? No
9. You were much more active or did many more things than usual?	Yes9. You were much more active or did many more things than usual? Yes	No9. You were much more active or did many more things than usual? No
10. You were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night?	Yes10. You were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night? Yes	No10. You were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night? No
11. You were much more interested in sex than usual?	Yes11. You were much more interested in sex than usual? Yes	No11. You were much more interested in sex than usual? No
12. You did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?	Yes12. You did things that were unusual for you or that other people might have thought were excessive, foolish, or risky? Yes	No12. You did things that were unusual for you or that other people might have thought were excessive, foolish, or risky? No
13. Spending money got you or your family in trouble?	Yes13. Spending money got you or your family in trouble? Yes	No13. Spending money got you or your family in trouble? No

2. If you answered YES to more than one of the above, have several of these happened during the same period of time? *

3. How much of a problem did any of these cause you, such as being unable to work, having family, legal, or money problems, or getting into arguments or fights? *

No problems	Minor problems	Moderate problems	Severe problems
No problemsNo problems No problems	Minor problemsNo problems Minor problems	Moderate problemsNo problems Moderate problems	Severe problemsNo problems Severe problems

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Mood Disorder Questionnaire