Mood Disorder Questionnaire (MDQ)

Name: Date:

Instructions: Check ( ✓) the answer that best applies to you.

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?

…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 you didn’t really miss it?

…you were much more talkative or spoke 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 in 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? Please check 1 response only.

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?
Please check 1 response only.

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?

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

This questionnaire should be used as a starting point. It is not 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 doctor.
Adapted from Hirschfeld R, Williams J, Spitzer RL, et al. Development and validation of a screening instrument for bipolar spectrum
disorder: the Mood Disorder Questionnaire. Am J Psychiatry. 2000;157:1873-1875.
ADULT ADHD SELF-REPORT SCALE (ASRS-V1.1) SYMPTOM CHECKLIST
Patient: _____________________________________________________________________________________________ Date Completed: ___________________

Please answer the questions below, rating yourself on each of the criteria shown using the
scale on the right side of the page. As you answer each question, place an X in the box that Very
Never Rarely Sometimes Often
best describes how you have felt and conducted yourself over the past 6 months. Please give often
this completed checklist to your healthcare professional to discuss during your appointment.

PART A

How often do you have trouble wrapping up the final details of a project, once the
challenging parts have been done?

How often do you have difficulty getting things in order when you have to do a task
that requires organization?

How often do you have problems remembering appointments or obligations?

When you have a task that requires a lot of thought, how often do you avoid or delay
getting started?

How often do you fidget or squirm with your hands or feet when you have to sit down
for a long time?

How often do you feel overly active and compelled to do things, like you were driven
by a motor?

PART B

How often do you make careless mistakes when you have to work on a boring or difficult
project?

How often do you have difficulty keeping your attention when you are doing boring or
repetitive work?

How often do you have difficulty concentrating on what people say to you, even when
they are speaking to you directly?

How often do you misplace or have difficulty finding things at home or at work?

How often are you distracted by activity or noise around you?

How often do you leave your seat in meetings or in other situations in which you are
expected to stay seated?

How often do you feel restless or fidgety?

How often do you have difficulty unwinding and relaxing when you have time to
yourself?

How often do you find yourself talking too much when you are in social situations?

When you’re in a conversation, how often do you find yourself finishing the sentences of the
people you are talking to, before they can finish it themselves?

How often do you have difficulty waiting your turn in situations when turn taking is required?

How often do you interrupt others when they are busy?

© World Health Organization 2003 All rights reserved. Based on the Composite International Diagnostic Interview © 2001 World Health Organization. All rights reserved. Used with permission.
Requests for permission to reproduce or translate —whether for sale or for noncommercial distribution—should be addressed to Professor Ronald Kessler, PhD, Department of Health Care Policy,
Harvard Medical School, (fax: +011 617-432-3588; email: ronkadm@[Link]).
 PATIENT SAFETY PLAN

1) Warning signs (thoughts, images, mood situation, behavior) that a crisis

A)
B)
C)

2) Internal coping strategies – things the pt can do to take their mind off of their
problems WITHOUT contacting another person (relaxation technique,
physical activity/hobby)

A)
B)
C)

3) People and social settings that provide distraction:

A)Name and Phone number:

4) People whom pt can ask for help:

A)Name/Phone:
B) Name/Phone:
C) Name/Phone:

5) Professionals or agencies the pt can contact during a crisis:

A) Clinician Name: Faiz Faseehuddin M.D. – Via the talkspace app

B) Clinician Name/Phone number or pager:

C) Emergent/Urgent Care Services: 911

D) Suicide Prevention Phone: 1-800-273-TALK

6) Make the environment safe: Please remove Guns, knives, etc or have them
locked up by a family member
AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION/MEDICAL
RECORDS

Authorization

I authorize __________________ (Therapist/healthcare provider) to use and disclose the protected

This authorization for release of information covers the period of healthcare from:

( ) The entire course of treatment (All past, present and future treatment)
( ) The period of healthcare from ____________ to __________________

Scope of Authorization

( ) I authorize the release of my complete health record including HIV/AIDS, communicable diseases, and
the treatment of alcohol or drug abuse

( ) I authorize only the release of dates of treatment

( ) I authorize only the release of dates of treatment and diagnosis

( ) I authorize the release of my complete health record except

() HIV/AIDS, communicable diseases

(Medical record does not include psychotherapy notes or any treatment transcript)

This authorization shall be in effect until __/__/_____ or will expire one year from the date of
signature.

I understand that I have the right to revoke this authorization, in writing at any time. I understand that
revocation will not be effective to the extent that any person or entity has already acted in reliance on
my authorization.

I understand that the information used or disclosed pursuant to this authorization may be disclosed by
the recipient and may no longer be protected by federal or state law.
Name/entity and address to whom this information will be sent to:

_________________________________________________
Address City State Zip

__________________________________
Signature of patient or representative

__________________________________
Printed name of patient

__________________________________
Patient Date of Birth

__________________________________
Patient State of Residence

_____________________________________________ ______________________
Printed name of personal representative (if applicable) Relationship to the patient

__________________________________
Signature of Minor (if applicable

__________________________________
Date