New Patient Questionnaire (Part 1)

Name:

Birthday:

Gender: Male Female

Email:

Phone:
(Please include area code)

City:

Instructions:
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.

DEPRESSION INVENTORY

Please select the one response to each item that best describes you for the past seven days.

Falling Asleep:

0: I never take longer than 30 minutes to fall asleep.
1: I take at least 30 minutes to fall asleep, less than half the time.
2: I take at least 30 minutes to fall asleep more than half the time.
3: I take more than 60 minutes to fall asleep, more than half the time.

Sleep During the Night:

0: I do not wake up at night.
1: I have a restless, light sleep with a few brief awakenings each night.
2: I wake up at least once a night, but I go back to sleep easily.
3: I awaken more than once a night and stay awake for 20 minutes or more, more than half the time.

Waking Up Too Early:

0: Most of the time, I awaken no more than 30 minutes before I need to get up.
1: More than half the time, I awaken more than 30 minutes before I need to get up.
2: I almost always awaken at least one hour or so before I need to, but I go back to sleep eventually.
3: I awaken at least one hour before I need to, and can't go back to sleep.

Sleeping Too Much:

0: I sleep no longer than 7-8 hours/night, without napping during the day.
1: I sleep no longer than 10 hours in a 24-hour period including naps.
2: I sleep no longer than 12 hours in a 24-hour period, including naps.
3: I sleep longer than 12 hours in a 24-hour period including naps.

Feeling Sad:

0: I do not feel sad.
1: I feel sad less than half the time.
2: I feel sad more than half the time.
3: I feel sad nearly all of the time.

Feeling Irritable:

0: I do not feel irritable.
1: I feel irritable less than half the time.
2: I feel irritable more than half the time.
3: I feel extremely irritable nearly all of the time.

Feeling Anxious or Tense:

0: I do not feel anxious or tense.
1: I feel anxious (tense) less than half the time.
2: I feel anxious (tense) more than half the time.
3: I feel extremely anxious (tense) nearly all of the time.

Response of Your Mood to Good or Desired Events:

0: My mood brightens to a normal level which lasts for several hours when a good event occurs.
1: My mood brightens but I do not feel like my normal self when good events occur.
2: My mood brightens only somewhat to a rather limited range of desired events.
3: My mood does not brighten at all, even when very good or desired events occur in my life.

Mood in Relation to the Time of Day:

0: There is no regular relationship between my mood and the time of day.
1: My mood often relates to the time of day because of environmental events (e.g. being alone, working).
2: My mood is clearly and predictably better or worse at a particular time each day.

Is your mood typically worse in the morning, afternoon, or night? (Select One)

Morning
Afternoon
Night

Is your mood variation attributed to the environment?

The Quality of Your Mood:

0: The mood (internal feelings) that I experience is very much a normal mood.
1: My mood is sad, but this sadness is pretty much like the sad mood I would feel if someone close to me died or left.
2: My mood is sad, but this sadness has a rather different quality to it than the sadness I would feel if someone close to me died or left.
3: My mood is sad, but this sadness is different from the type of sadness associated with grief or loss.

Please complete ONE of the following two questions (not both)

Decreased Appetite:

0: There is no change in my usual appetite.
1: I eat somewhat less often or lesser amounts of food than usual.
2: I eat much less than usual and only with personal effort.
3: I rarely eat within a 24-hour period, and only with extreme personal effort or when others persuade me to eat.

Increased Appetite:

0: There is no change from my usual appetite.
1: I feel a need to eat more frequently than usual.
2: I regularly eat more often and/or greater amounts of food than usual.
3: I feel driven to overeat both at mealtime and between meals.

Please complete ONE of the following two questions (not both)

Decreased Weight (Within the Last Two Weeks):

0: I have not had a change in my weight.
1: I feel as if I've had a slight weight loss.
2: I have lost 2 pounds or more.
3: I have lost 5 pounds or more.

Increased Weight (Within the Last Two Weeks):

0: I have not had a change in my weight.
1: I feel as if I've had a slight weight gain.
2: I have gained 2 pounds or more.
3: I have gained 5 pounds or more.

Concentration/Decision Making:

0: There is no change in my usual capacity to concentrate or make decisions.
1: I occasionally feel indecisive or find that my attention wanders.
2: Most of the time, I struggle to focus my attention or to make decisions.
3: I cannot concentrate well enough to read or cannot make even minor decisions.

View of Myself:

0: I see myself as equally worthwile and deserving as other people.
1: I am more self-blaming than usual.
2: I largely believe that I cause problems for others.
3: I think almost constantly about major and minor defects in myself.

View of My Future:

0: I have an optimistic view of my future.
1: I am occasionally pessimistic about my future.
2: I'm pretty certain that my immediate future (1-2 months) does not hold much promise of good things for me.
3: I see no hope of anything good happening to me anytime in the future.

Thoughts of Death and Suicide:

0: I do not think of suicide or death.
1: I feel that life is empty or wonder if it's worth living.
2: I think of suicide or death several times a week for several minutes.
3: I think of suicide or death several times a day in some detail, or I have made specific plans for suicide or have actually tried to take my life.

General Interest:

0: There is no change from usual to how interested I am in other people or activities.
1: I notice that I am less interested in people or activities.
2: I find I have interest in only one or two of my formerly pursued activities.
3: I have virtually no interest in formerly pursued activities.

Energy Level:

0: There is no change in my usual level of energy.
1: I get tired more easily than usual.
2: I have to make a big effort to start or finish my usual daily activities (for example, shopping, homework, cooking, or going to work).
3: I really cannot carry out most of my usual daily activities because I just don't have the energy.

Capacity for Pleasure or Enjoyment (Excluding Sex):

0: I enjoy pleasurable activities just as much as usual.
1: I do not feel my usual sense of enjoyment from pleasurable activities.
2: I rarely get a feeling of pleasure from any activity.
3: I am unable to get any pleasure or enjoyment from anything.

Interest in Sex (Please Rate INTEREST, not Activity):

0: I'm just as interested in sex as usual.
1: My interest in sex is somewhat less than usual or I do not get the same pleasure from sex as I used to.
2: I have little desire for or rarely derive pleasure from sex.
3: I have absolutely no interest or derive no pleasure from sex.

Feeling Slowed Down:

0: I think, speak, and move at my usual rate of speed.
1: I find that my thinking is slowed down or my voice sounds dull or flat.
2: It takes me several seconds to respond to most questions and I'm sure my thinking is slowed.
3: I am often unable to respond to questions without extreme effort.

Feeling Restless:

0: I do not feel restless.
1: I'm often fidgety, wringing my hands, or need to shift how I am sitting.
2: I have impulses to move about and am quite restless.
3: At times, I am unable to stay seated and need to pace around.

Aches and Pains:

0: I don't have any feeling of heaviness in my arms or legs and don't have any aches or pains.
1: Sometimes I get headaches or pains in my stomach, back or joints but these pains are only sometimes present and they don't stop me from doing what I need to do.
2: I have these sorts of pains most of the time.
3: These pains are so bad they force me to stop what I am doing.

Other Bodily Symptoms:

0: I don't have any of these symptoms: heart pounding fast, blurred vision, sweating, hot and cold flashes, chest pain, heart turning over in chest, ringing in my ears, or shaking.
1: I have some of these symptoms but they are mild and are present only sometimes.
2: I have several of these symptoms and they bother me quite a bit.
3: I have several of these symptoms and when they occur I have to stop whatever I am doing.

Panic/Phobic Symptoms:

0: I have no spells of panic or specific fears (phobia) (such as animals or heights).
1: I have mild panic episodes or fears that do not usually change my behavior or stop me from functioning.
2: I have significant panic episodes or fears that force me to change my behavior but do NOT stop me from functioning.
3: I have panic episodes at least once a week or severe fears that stop me from carrying on my daily activities.

Constipation/Diarrhea:

0: There is no change in my usual bowel habits.
1: I have intermittent constipation or diarrhea which is mild.
2: I have diarrhea or constipation most of the time but it does not interfere with my day to day activities.
3: I have constipation or diarrhea for which I take medicine or which interferes with my day to day activities.

Interpersonal Sensitivity:

0: I have not felt rejected, slighted, criticized or hurt by others at all.
1: I have occasionally felt rejected, slighted, criticized or hurt by others.
2: I have often felt rejected, slighted, criticized or hurt by others, but these feelings have had only slight effects on my relationships or work.
3: I have often felt rejected, slighted, or criticized or hurt by others and these feelings have impaired my relationships and work.

Leaden Paralysis/Physical Energy:

0: I have not experienced the physical sensation of feeling weighted down and without physical energy.
1: I have occasionally experienced periods of feeling physically weighted down and without physical energy, but without a negative effect on work, school or activity level.
2: I feel physically weighted down (without physical energy) more than half the time.
3: I feel physically weighted down (without physical energy) most of the time, several hours per day, several days per week.

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.

0: Not at all
1: A little bit
2: Somewhat
3: Very much
4: Extremely

I am bothered by blushing in front of people.

0: Not at all
1: A little bit
2: Somewhat
3: Very much
4: Extremely

Parties and social events scare me.

0: Not at all
1: A little bit
2: Somewhat
3: Very much
4: Extremely

I avoid talking to people I don't know.

0: Not at all
1: A little bit
2: Somewhat
3: Very much
4: Extremely

Being criticized scares me a lot.

0: Not at all
1: A little bit
2: Somewhat
3: Very much
4: Extremely

Fear of embarrassment causes me to avoid doing things or speaking to people.

0: Not at all
1: A little bit
2: Somewhat
3: Very much
4: Extremely

Sweating in front of people causes me distress.

0: Not at all
1: A little bit
2: Somewhat
3: Very much
4: Extremely

I avoid going to parties.

0: Not at all
1: A little bit
2: Somewhat
3: Very much
4: Extremely

I avoid activities in which I am the centre of attention.

0: Not at all
1: A little bit
2: Somewhat
3: Very much
4: Extremely

Talking to strangers scares me.

0: Not at all
1: A little bit
2: Somewhat
3: Very much
4: Extremely

I avoid having to give speeches.

0: Not at all
1: A little bit
2: Somewhat
3: Very much
4: Extremely

I would do anything to avoid being criticized.

0: Not at all
1: A little bit
2: Somewhat
3: Very much
4: Extremely

Heart palpitations bother me when I am around people.

0: Not at all
1: A little bit
2: Somewhat
3: Very much
4: Extremely

I am afraid of doing things when people might be watching.

0: Not at all
1: A little bit
2: Somewhat
3: Very much
4: Extremely

Being embarrassed or looking stupid are among my worst fears.

0: Not at all
1: A little bit
2: Somewhat
3: Very much
4: Extremely

I avoid speaking to anyone in authority.

0: Not at all
1: A little bit
2: Somewhat
3: Very much
4: Extremely

Trembling or shaking in front of others is distressing to me.

0: Not at all
1: A little bit
2: Somewhat
3: Very much
4: Extremely

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?

ANXIETY QUESTIONNAIRE

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?

ADHD QUESTIONNAIRE

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

0: Not at all, never
1: Just a little, once in a while
2: Pretty much, often
3: Very much, very frequently

I am always on the go as if driven by a motor

0: Not at all, never
1: Just a little, once in a while
2: Pretty much, often
3: Very much, very frequently

I'm disorganized

0: Not at all, never
1: Just a little, once in a while
2: Pretty much, often
3: Very much, very frequently

It's hard for me to keep track of several things at once

0: Not at all, never
1: Just a little, once in a while
2: Pretty much, often
3: Very much, very frequently

I'm bored easily

0: Not at all, never
1: Just a little, once in a while
2: Pretty much, often
3: Very much, very frequently

I have a short fuse/hot temper

0: Not at all, never
1: Just a little, once in a while
2: Pretty much, often
3: Very much, very frequently

I seek out fast paced, exciting activities

0: Not at all, never
1: Just a little, once in a while
2: Pretty much, often
3: Very much, very frequently

I feel restless inside even when I'm sitting still

0: Not at all, never
1: Just a little, once in a while
2: Pretty much, often
3: Very much, very frequently

Things I hear or see distract me from what I'm doing

0: Not at all, never
1: Just a little, once in a while
2: Pretty much, often
3: Very much, very frequently

I can't get things done unless there's an absolute deadline

0: Not at all, never
1: Just a little, once in a while
2: Pretty much, often
3: Very much, very frequently

I have trouble getting started on a task

0: Not at all, never
1: Just a little, once in a while
2: Pretty much, often
3: Very much, very frequently

I intrude on others' activities

0: Not at all, never
1: Just a little, once in a while
2: Pretty much, often
3: Very much, very frequently

My moods are unpredictable

0: Not at all, never
1: Just a little, once in a while
2: Pretty much, often
3: Very much, very frequently

I'm absent minded in daily activities

0: Not at all, never
1: Just a little, once in a while
2: Pretty much, often
3: Very much, very frequently

I have difficulty remaining quiet

0: Not at all, never
1: Just a little, once in a while
2: Pretty much, often
3: Very much, very frequently

I tend to squirm or fidget

0: Not at all, never
1: Just a little, once in a while
2: Pretty much, often
3: Very much, very frequently

I can't keep my mind on something unless it's really interesting

0: Not at all, never
1: Just a little, once in a while
2: Pretty much, often
3: Very much, very frequently

I talk excessively, or too loudly

0: Not at all, never
1: Just a little, once in a while
2: Pretty much, often
3: Very much, very frequently

I have difficulty waiting

0: Not at all, never
1: Just a little, once in a while
2: Pretty much, often
3: Very much, very frequently

I forget directions only moments after they have been given

0: Not at all, never
1: Just a little, once in a while
2: Pretty much, often
3: Very much, very frequently

I impulsively say the wrong thing in social situations

0: Not at all, never
1: Just a little, once in a while
2: Pretty much, often
3: Very much, very frequently

I have difficulty listening to others

0: Not at all, never
1: Just a little, once in a while
2: Pretty much, often
3: Very much, very frequently

I often lose things such as car keys, shoes, money, credit cards, wallets or glasses

0: Not at all, never
1: Just a little, once in a while
2: Pretty much, often
3: Very much, very frequently

I tend to start many projects but finish few

0: Not at all, never
1: Just a little, once in a while
2: Pretty much, often
3: Very much, very frequently

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: