Mood Disorder Questionnaire
If you or someone you care for wants to better understand their symptoms,
Name:
answer the questions below and bring this form to the next appointment with
your healthcare provider to discuss your answers. Be sure to tell them about Date:
manic and depressive symptoms as they can both be signs of bipolar disorder.
Please answer the questions as best you can by checking the appropriate boxes.
1. Has there ever been a period of time when you were not your usual self and:
Yes No
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?
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; and/or
getting into arguments or fights)
No Problem Minor Problem Moderate Problem Serious Problem
This questionnaire is provided as a resource by Intra-Cellular Therapies, Inc. It is not a diagnostic tool or a substitute for a full medical evaluation.
Bipolar disorder is a complex illness, and an accurate, thorough diagnosis can only be made through a personal evaluation by your healthcare provider.
Reference: 1. Development and Validation of a Screening Instrument for Bipolar Spectrum Disorder: The Mood Disorder Questionnaire. Robert M.A.
Hirschfeld, Janet B.W. Williams, Robert L. Spitzer, Joseph R. Calabrese, Laurie Flynn, Paul E. Keck, Jr., Lydia Lewis, Susan L. McElroy, Robert M. Post,
Daniel J. Rapport, James M. Russell, Gary S. Sachs, and John Zajecka. American Journal of Psychiatry 2000 157:11, 1873-1875.
Reprinted with permission from the American Journal of Psychiatry,
(Copyright © 2000). American Psychiatric Association. All Rights Reserved.
© 2022 Intra-Cellular Therapies, Inc. All rights reserved.
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