Personal Information

Full Name

Age

Gender

Mood Symptoms

Have you experienced periods of unusually elevated or irritable mood?

Yes No

Do these periods last for at least 4 days?

Yes No

During these periods, do you feel more energetic or active than usual?

Yes No

Do you notice changes in your sleep patterns?

Yes No

Have you had increased talkativeness or rapid speech?

Yes No

Have you engaged in risky behaviors (spending, driving, sexual, etc.) during high mood periods?

Yes No

Have you experienced periods of low mood, loss of interest, or hopelessness?

Yes No

Do these periods last for at least 2 weeks?

Yes No

Do you struggle with concentration or making decisions?

Yes No

Is there a family history of Bipolar Disorder or other mental health conditions?

Yes No

Please provide any additional information or comments: