Mood Disorder Questionnaire

Name
Date of Birth:
Date:

Both the manic and the depressive symptoms of bipolar disorder can have a negative impact on your life, your relationships, even your job.

Talking to your doctor about all your symptoms is an important first step to finding out whether you have bipolar disorder.

Answering the questions on this form, and discussing the responses with your doctor, may help you do that. It will take about 5 minutes to complete.

(Please answer the questions as best you can by putting a check in the appropriate box)

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 that you didn't really miss it?
...you were 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?

If you checked Yes to more than one of the above, have several of these ever happened during the same period of time?

If you checked Yes to more than one of the above, have several of these ever happened during the same period of time?

How much of a problem did any of these cause you?

(like being unable to work; having family, money, or legal troubles; and/or getting into arguments or fights)
How much of a problem did any of these cause you? (like being unable to work; having family, money, or legal troubles; and/or getting into arguments or fights)

Reference 1. Hirschfeld RMA, Lewis L Vornik LA, J ClIn Psychiatry 2003;64(2)161-174

 

The Mood Disorder Questionnaire (MD was developed by Robert M. A. Hirschfeld, MD (University of Texas Medical Branch), and published in the Am J Psychiatry. (Hlrschfeid RMA, Williams JBW, Spitzer RL, et aL. Development and validation of a screening instrument for bipolar spectrum disorder the Mood Disorder Questionnaire. Am J Psychiatry. 2000;157(11);1873-1875)

©2009, 2000 Robert M.A Hlrschfeld, MD