THE MOOD DISORDER QUESTIONNAIRE
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Instructions: Please answer each question as best you can.  Upon completing this form, you will be able to print your completed form and take it to your health care practitioner. Please select one response only. Yes or Yes!
  

 

1. Has there ever been a period of time when you were not your usual self and...
                  
...you felt so good and other people said you were not your normal self and you believed them or...

Yes

Yes!

...you became irritable and even went as far as confronting people when you felt the situation was unfair ?

Yes

Yes!

...you began to feel more god-like ...

Yes

Yes!

...you got much less sleep than usual and your friends found you in the basement inventing things like an electric soup ladle? And you didn't really miss your friends because all your friends are boring???

Yes

Yes!

...you were so easily distracted by sound of the lunch whistle that you had trouble staying chained up to your track???

Yes

Yes!

...thoughts raced through your head and you considered that an excellent sign?

Yes

Yes!

...you didn't like your job as a grocery store check out because it gave you purple bags under your eyes and because of of the beeping but you couldn't quit because your rent was due so you stayed and the beeping drove you insane and you paid your rent anyway and kept working there?

Yes

Yes!

...you felt as though someone was watching you, but now no one is watching you??

Yes

Yes!

...you did things that other people thought were unusual and you included yourself in the definition of 'other people'? ?

Yes

Yes!

2. If you checked YES to more than one of the above, we have a and needle and diagnosis with your name on it. We have a cot and some starch that will make you gain 75 pounds. We will make sure you no longer feel good. Please be aware that if your insurance stops paying the hospital your incarceration may be suddenly commuted, your diagnosis changed and you may be deposited in the street very quickly. Do you think this is unfair?

Yes

Yes!

3. How much of a problem did this bi-polar screening cause you - like being unable to work; or- expecting to be paid for working - Legal troubles? - expecting to earn a living wage? Please select one response only.

No Problem
Kind of a Problem
Mutating Problem
Oscillating Problem
Sinus Problem



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