Mood Disorder Questionnaire

Instructions: This questionnaire is an important part of providing you with the best health care possible. Your answers will help in understanding problems that you may have. Please answer each question as best you can by circling your answer.

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	Y  N
you were so irritable that you shouted at people or started fights or arguments?	Y  N
you felt much more self-confident than usual?	Y  N
you got much less sleep than usual and found you didn’t really miss it?	Y  N
you were much more talkative or spoke much faster than usual?	Y  N
thoughts raced through your head or you couldn’t slow your mind down?	Y  N
you were so easily distracted by things around you that you had trouble concentrating or staying on track?	Y  N
you had much more energy than usual?	Y  N
you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night?	Y  N
you were much more interested in sex than usual?	Y  N
you did things that were unusual for you or that other people might have thought were excessive, foolish or risky?	Y  N
you spent money that got you or your family into trouble?	Y  N
If you circled “Y”/Yes to answer more than one of the above, have several of these ever happened to you during the same period?	Y  N
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? (Please circle one response only.)
No problem.      Minor problem.      Moderate problem.      Serious problem.
Have any of your blood relatives (children, siblings, parents, grandparents, aunts, uncles) had manic-depressive illness or bipolar disorder?	Y  N
Has a health professional ever told you that you have manic-depressive illness or bipolar disorder?	Y  N

Checklist for Signs of Social Anxiety

Instructions: Please take a moment to think about whether any of the following statements apply to you. If you answer "yes" to some of these statements, you may benefit from treatment for social anxiety.

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

1. I feel anxious or nervous when making presentations for work or school (or almost always avoid these situations).	Y  N
2. I feel anxious or nervous when interacting with others (or almost always avoid these situations).	Y  N
3. I feel anxious or nervous eating or drinking in front of others.	Y  N
4. I have trouble being assertive with family, friends, or strangers.	Y  N
5. I have difficulty interacting with authority figures (i.e., boss or teacher).	Y  N
6. I have used alcohol or tranquilizers to calm my nerves before interacting with others.	Y  N
7. I am afraid I will do something to humiliate or embarrass myself in a social situation.	Y  N
8. I fear being judged as inadequate or incompetent by others.	Y  N

What I would like less of/more of

What I want to experience less of/don’t want any more (do, think, feel)	What I want instead/to experience more of (do, think, feel)