Please answer each question to the best of your ability.

Please note, all fields are required.

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

You felt so good or hyper that other people thought you were not your normal self or 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 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

4. Have any of your blood relatives had manic-depressive illness or bipolar disorder?

i.e. Children, siblings, parents, grandparents, aunts, and uncles.

Yes

No

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

Yes

No

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