| RPT |
.| .| Mood Disorders Questionnaire| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB:
have several of these ever happened during the same period of time?| <*Answer_6534*>| 3. How much of a problem did any of these cause you, like being unable to work; having family, money, or
legal troubles; or getting into arguments or fights?| <*Answer_6535*>| 4. Have any of your blood relatives (i.e. children, siblings, parents, grandparents, aunts, uncles) had manic-depressive
illness or bipolar disorder?| <*Answer_7292*>| 5. Has a health professional ever told you that you have manic-depressive illness or bipolar disorder?| <*Answer_7293*>| | (c) 2000 by The
University of Texas Medical Branch.| | Information contained in this note is based on a self-report assessment and is not sufficient to use alone for diagnostic purposes. Assessment results should
be verified for accuracy and used in conjunction with other diagnostic activities and procedures.| $~
<.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | <.DLL_String.>| | Questions and Answers| | 1. Has there ever been a time when you were not your usual self and...| | 1A.
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?| <*Answer_6521*>| 1B. you were so irritable that you shouted
at people or started fights or arguments?| <*Answer_6522*>| 1C. you felt much more self-confident than usual?| <*Answer_6523*>| 1D. you got much less sleep than usual and found you didn't
really miss it?| <*Answer_6524*>| 1E. you were much more talkative or spoke faster than usual?| <*Answer_6525*>| 1F. thoughts raced through your head or you couldn't slow your mind down?|
<*Answer_6526*>| 1G. you were so easily distracted by things around you that you had trouble concentrating or staying on track?| <*Answer_6527*>| 1H. you had much more energy than usual?|
<*Answer_6528*>| 1I. you were much more active or did many more things than usual?| <*Answer_6529*>| 1J. you were much more social or outgoing than usual? For example, you telephoned friends in
the middle of the night.| <*Answer_6530*>| 1K. you were much more interested in sex than usual?| <*Answer_6531*>| 1L. you did things that were unusual for you or that other people might have
thought were excessive, foolish, or risky?| <*Answer_6532*>| 1M. spending money got you or your family into trouble?| <*Answer_6533*>| 2. If you answered YES to more than one of the above,
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