Instructions:

Please answer each question as best you can.
Upon completing this form, print your completed form
and take it to your health care practitioner.
This screening instrument is not a substitute for
a full medical and psychiatric evaluation.
If you or your family are concerned about
a family member, or your mental condition
please contact a healthcare professional immediately.

 

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?	Yes	No
...you were so irritable that you shouted at people or started fights or arguments?	Yes	No
...you felt much more self-confident than usual?	Yes	No
...you got much less sleep than usual and found you didn't really miss it?	Yes	No
...you were much more talkative or spoke much faster than usual?	Yes	No
...thoughts raced through your head or you couldn't slow your mind down?	Yes	No
...you were so easily distracted by things around you that you had trouble concentrating or staying on track?	Yes	No
...you had much more energy than usual?	Yes	No
...you were much more active or did many more things than usual?	Yes	No
...you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night?	Yes	No
...you were much more interested in sex than usual?	Yes	No
...you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?	Yes	No
...spending money got you or your family into trouble?	Yes	No
2. If you checked YES to more than one of the above, have several of these ever happened during the same period of time?	Yes	No
3. How much of a problem did any of these cause you - like being unable to work; having family, money or legal troubles' getting into arguments or fights?  No Problem  Minor Problem  Moderate Problem  Serious Problem Resource Mental Health Infosource Bipolar Link       Disclaimer: The material on this site is intended as an educational tool to offer information about alternative healing and health maintenance options available to the health care consumer today. The advice on this site is intended solely for informational and educational purposes and not as medical advice. Please consult a medical professional if you have questions about your medical health.