Name *

First Name

Last Name

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 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 in 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 able to work; having family, money, or legal troubles; getting into arguments or fights? *

No Problem

Minor Problem

Moderate Problem

Serious Problem

4. Have any of your blood relatives (ie, children, siblings, parents, grandparents, aunts, uncles) had manic-depressive illness or bipolar disorder? *

Yes

No

5. Has a health professional ever told you that you have manic-depressive illness or bipolar disorder? *

Yes

No