(Please include area code)
Please answer the following questions. More questions may appear as you go, so please start at the top and work your way down.
If unsure about a question, leave it unanswered.
Please select the one response to each item that best describes you for the past seven days.
Sleep During the Night:
Waking Up Too Early:
Sleeping Too Much:
Feeling Anxious or Tense:
Response of Your Mood to Good or Desired Events:
Mood in Relation to the Time of Day:
Is your mood typically worse in the morning, afternoon, or night? (Select One)
Is your mood variation attributed to the environment?
The Quality of Your Mood:
Please complete ONE of the following two questions (not both)
Decreased Weight (Within the Last Two Weeks):
Increased Weight (Within the Last Two Weeks):
View of Myself:
View of My Future:
Thoughts of Death and Suicide:
Capacity for Pleasure or Enjoyment (Excluding Sex):
Interest in Sex (Please Rate INTEREST, not Activity):
Feeling Slowed Down:
Aches and Pains:
Other Bodily Symptoms:
Leaden Paralysis/Physical Energy:
OBSESSIVE COMPULSIVE INVENTORY
Please answer each of these questions by selecting "Yes" or "No"
Do you have unwanted ideas, images or impulses that seem silly, nasty or horrible?
Do you worry excessively about dirt, germs or chemicals?
Are you constantly worried that something bad will happen because you forgot something important - like locking the door or turning off appliances?
Are you afraid you will act or speak aggressively when you really don't want to?
Are you always afraid you will lose something of importance?
Are there things you feel you must do excessively or thoughts you must think repeatedly, in order to feel comfortable?
Do you wash yourself or things around you excessively?
Do you have to check things over and over again or repeat them many times to be sure they are done properly?
Do you avoid situations or people you worry about hurting by aggressive words or deeds?
Do you keep many useless things because you feel that you can't safely throw them away?
SOCIAL PHOBIA INVENTORY
Please select how much the following problems have bothered you in the past week. Select only one answer for each problem, and be sure to answer all items.
I am afraid of people in authority.
I am bothered by blushing in front of people.
Parties and social events scare me.
I avoid talking to people I don't know.
Being criticized scares me a lot.
Fear of embarrassment causes me to avoid doing things or speaking to people.
Sweating in front of people causes me distress.
I avoid going to parties.
I avoid activities in which I am the centre of attention.
Talking to strangers scares me.
I avoid having to give speeches.
I would do anything to avoid being criticized.
Heart palpitations bother me when I am around people.
I am afraid of doing things when people might be watching.
Being embarrassed or looking stupid are among my worst fears.
I avoid speaking to anyone in authority.
Trembling or shaking in front of others is distressing to me.
SUBSTANCE ABUSE QUESTIONNAIRE
Within the past year:
Have you felt you should reduce your use of alcohol or other substances (caffeine, tobacco, marijuana, cocaine, other)?
Have you been irritated by other people criticizing your substance use?
Have you felt remorseful about your use of alcohol or other subtances?
Have you felt you needed to use alcohol first thing in the morning in order to be able to face the day?
Have you worried excessively or been anxious about several things OVER THE PAST 6 MONTHS? If NO - skip over the next question.
Are these worries present most days?
Do you find it difficult to control the worries or do they interfere with your ability to focus on what you are doing?
When you were anxious OVER THE PAST 6 MONTHS, did you, most of the time:
Listed below are items concerning behaviors or problems. Read each item carefully and decide how much or how frequently each item describes you over your lifetime. Indicate your response for each item by selecting the number that corresponds to your choice.
I interrupt others when talking
I am always on the go as if driven by a motor
It's hard for me to keep track of several things at once
I'm bored easily
I have a short fuse/hot temper
I seek out fast paced, exciting activities
I feel restless inside even when I'm sitting still
Things I hear or see distract me from what I'm doing
I can't get things done unless there's an absolute deadline
I have trouble getting started on a task
I intrude on others' activities
My moods are unpredictable
I'm absent minded in daily activities
I have difficulty remaining quiet
I tend to squirm or fidget
I can't keep my mind on something unless it's really interesting
I talk excessively, or too loudly
I have difficulty waiting
I forget directions only moments after they have been given
I impulsively say the wrong thing in social situations
I have difficulty listening to others
I often lose things such as car keys, shoes, money, credit cards, wallets or glasses
I tend to start many projects but finish few
BIPOLAR SYMPTOM CHECKLIST
If you experience many of the following symptoms, you may be experiencing a manic or depressive episode. Indicate those symptoms experienced IN THE PAST WEEK:
Indicate those symptoms you have experienced FOR AT LEAST ONE WEEK CONTINUOUSLY IN YOUR LIFETIME: