MoodCheck

Part A. Please place a check after the statements below that accurately describe you.
During times when I am not using drugs or alcohol:
I notice that my mood and/or energy levels shift drastically from time to time.
At times, I am moody and/or energy level is very low, and at other times, and very high.
During my "low" phases, I often feel a lack of energy, a need to stay in bed or get extra
sleep, and little or no motivation to do things I need to do.
I often put on weight during these periods.
During my low phases, I often feel "blue," sad all the time, or depressed.
Sometimes, during the low phases, I feel helpless or even suicidal.
During the low phases, my ability to function at work or socially is impaired.
Typically, the low phases last for a few weeks, but sometimes they last only a few days.
I also experience a period of "normal" mood in between mood swings, during which my
mood and energy level feels "right" and my ability to function is not disturbed.
I then notice a marked shift or "switch" in the way I feel.
My energy increases above what is normal for me, and I often get many things done I would
not ordinarily be able to do.
Sometimes during those "high" periods, I feel as if I have too much energy or feel "hyper".
During these high periods, I may feel irritable, "on edge," or aggressive.
During the high periods, I may take on too many activities at once.
During the high periods, I may spend money in ways that cause me trouble.
I may be more talkative, outgoing or sexual during these periods.
Sometimes, my behavior during the high periods seems strange or annoying to others.
Sometimes, I get into difficulty with co-workers or police during these high periods.
Sometimes, I increase my alcohol or nonprescription drug use during the high periods.
Total
Part B. The statements in Part A (not just those checked) describe me (circle one of the answers below):

Not at all A little Fairly well Very well

Add the number in parentheses in Part B to your checkmark total from Part A. ________

Part C.
Please indicate whether any of your (blood) relatives have had any of these concerns:

Grandparents Parents Aunts/Uncles Brothers/Sisters Children

Has a health professional ever told you that you have manic-depressive illness or bipolar
Yes No
disorder?
Have you ever attempted suicide? Yes No
(please continue with part D, over)
MoodCheck
Part D.
How old were you when you As long High
Grade Middle school
first were depressed? as I can 18-24 > 24
school school
(circle one) remember
How many episodes of
One 2-4 5-6 >10
depression have you had?
Have antidepressants ever Excessive Severe Racing Talking
Agitation Irritability a lot
caused: (circle all that apply) energy insomnia thoughts
How many antidepressants
None 1 2 3 >3
have you tried, if any?
Has an antidepressant you took
worked at first, then stopped No Yes
working?
Do your episodes start
Gradually Cant say Suddenly
gradually, or suddenly?
Do your episodes stop
Gradually Cant say Suddenly
gradually, or suddenly?
Did you have an episode after Within 2
No Within 6 months Within 2 months
giving birth? weeks
Are your moods much different
No effect of time of year Yes, seasonal shifts
at different times of year?
When you are depressed, do
No Sleep less Sleep more
you sleep differently?
When you are depressed, do
No Eat less Eat more
you eat differently?
When you are depressed, what Extremely low,
Nothing It varies a lot Very low can hardly move
happens to your energy?
In episodes, have you lost
contact with reality? (delusions,
No Yes
voices, people thought you
were odd)

If your total score from Parts A and B is greater than 16; or if you have lots of circles in shaded
boxes on this page, you may need to learn more about mood swings without mania. See
www.PsychEducation.org . This is something to learn about, not necessarily about you.

If your total score from Parts A and B is less than 10, and you have few circles in shaded boxes
on this page, antidepressants are probably okay, if you and your doctor choose to use them.
They can occasionally cause: unusual thoughts, including violent and suicidal ones; irritability;
too much energy; and severe sleep problems. Contact your doctor if you think any of these
might be happening to you.

Your Name_________________________________ Date ______________

MoodCheck is a public document but may not be used for profit. To download, see the Primary Care Providers
Resource Center at www.PsychEducation.org .