INSTRUCTIONS: Please answer each question to the best of your ability.





1. Has there ever been a period of time when you were not your usual self and...



 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?




 were so irritable that you shouted at people or started fights or arguments?


 felt much more self-confident than usual?


 got much less sleep than usual and found you didn’t really miss it?


 were much more talkative or spoke much faster than usual?






...thoughts raced through your head or you couldn’t slow your mind down?


 were so easily distracted by things around you that you had trouble


concentrating or staying on track?




 had much more energy than usual?


 were much more active or did many more things than usual?


 were much more social or outgoing than usual, for example, you


telephoned friends in the middle of the night?




 were much more interested in sex than usual?


 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 into 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?



3.How much of a problem did any of these cause you – like being unable to work; having family, money or legal troubles; getting into arguments or fights?

No Problem 

Minor Problem 

Moderate Problem 

Serious Problem 






4. Have any of your blood relatives (i.e. 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?





Total = _____

© 2000 by The University of Texas Medical Branch. Reprinted with permission. This instrument is designed for screening purposes only and is not to be used as a diagnostic tool.