Instructions for patients: Please check ONE BOX ONLY for each of the questions below.
PART ONE:
Has there ever been a period of time when you were not yourself and...
| 1. | ...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? | Yes
No
|
| 2. | ...you were so irritable that you shouted at people or started fights or arguments? | Yes
No
|
| 3. | ...you felt much more self-confident than usual? | Yes
No
|
| 4. | ...you got much less sleep than usual and found you didn't really miss it? | Yes
No
|
| 5. | ...you were much more talkative or spoke much fast then usual? | Yes
No
|
| 6. | ...thoughts raced through your head or you couldn't slow your mind down? | Yes
No
|
| 7. | ...you were so easily distracted by things around you that you had trouble concentrating or staying on track? | Yes
No
|
| 8. | ...you had much more energy than usual? | Yes
No
|
| 9. | ...you were much more active or did many more things than usual? | Yes
No
|
| 10. | ...you were much more social or outgoing than usual—for example, you telephoned friends in the middle of the night? | Yes
No
|
| 11. | ...you were much more interested in sex than usual? | Yes
No
|
| 12. | ...you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky? | Yes
No
|
| 13. | ...spending money got you or your family into trouble? | Yes
No
|
If you checked YES to more than one of the questions in Part One, continue to Part Two and Part Three.
PART TWO:
| 1. | Did several of the situations that you said YES to ever happen during the same period of time? | Yes
No
|
PART THREE:
| 1. | How much of a problem did any of these situations cause you (like being unable to work; having family, money, or legal problems; and/or getting into serious arguments or fights)? | Yes
No
|
Having more than one illness at the same time can make it difficult to diagnosis and treat the different conditions. Illnesses that sometimes complicate an anxiety disorder include depression and substance abuse. With this in mind, please take a minute to answer the following questions:
| 1. | Have you experienced changes in sleeping or eating habits? | No Problem
Minor Problem Moderate Problem Serious Problem |
Please discuss the results of this questionnaire with your physician.
*Adapted from Hirschfeld RMA, et al. AM J Psychiatry. 2000; 157: 1873-1875.
