Pitts Davis Counseling Services

Name *

First

Last

Date *

1. Frequent feelings of nervousness or anxiety

2. Panic attacks

3. Avoidance of places due to fear of having an anxiety attack

4. Symptoms of heightened muscle tension (sore muscles, headaches)

5. Periods of heart pounding, nausea, or dizziness (not w/exercise)

6. Tendency to predict the worst

7. Multiple, persistent fears or phobias (dying, doing something crazy)

8. Conflict avoidance

9. Excessive fear of being judged or scrutinized by others

10. Easily startled or tendency to freeze in intense situations

11. Seemingly shy, timid, and easily embarrassed

12. Bites fingernails or picks skin

Q 1-12 Score: _______________

13. Persistent sad or empty mood

14. Loss of interest or pleasure from activities that are normally fun

15. Restlessness, irritability or excessive crying

16. Feelings of guilt, worthlessness, helplessness, hopelessness

17. Sleeping too much or too little, or early morning waking

18. Appetite changes / weight loss or weight gain through overeating

19. Decreased energy, fatigue, feeling "slowed down"

20. Thoughts of death or suicide, or suicide attempts

21. Difficulty concentrating, remembering, making decisions

22. Physical symptoms: headaches, chronic pain, digestive problems

23. Persistent negativity or low self esteem

24. Persistent feeling of dissatisfaction or boredom

Q 13-24 Score: _______________

Q 1-24 Score: _______________

25. Excessive or senseless worrying

26. Upset when things are out of place or don't go according to plan

27. Tendency to be oppositional or argumentative

28. Tendency to have repetitive negative or anxious thoughts

29. Tendency toward compulsive behaviors

30. Intense dislike of change

31. Tendency to hold grudges

32. Difficulty seeing options in situations

33. Tendency to hold on to own opinion and not listen to others

34. Needing to have things done a certain way or you become upset

35. Others complain you worry too much

36. Tendency to say no without first thinking about the question

Q 25-36 Score: _______________

37. Periods of abnormally happy, depressed or anxious mood

38. Periods of decreased need for sleep, energetic on much less sleep

39. Periods of grandiose thoughts and ideas (feeling very powerful)

40. Periods of increased talking or pressured speech

41. Periods of too many thoughts racing through your mind

42. Periods of increased energy level

43. Periods of poor judgment that leads to risk-taking behaviors

44. Periods of inappropriate social behavior

45. Periods of irritability or aggression

46. Periods of delusional or psychotic thinking

Q 37-46 Score: _______________

47. Short fuse or periods of extreme irritability

48. Periods of rage without being provoked

49. Often misinterprets comments as negative when they are not

50. Periods of spaciness or confusion

51. Periods of panic or fear for no specific reason

52. Visual or auditory changes (seeing shadows or hearing sounds)

53. Frequent periods of deja vu (feeling you've been somewhere you have never been)

54. Sensitivity or mild paranoia

55. Headaches or abdominal pain of uncertain origin

56. History of head injury or family history of violence/explosiveness

57. Dark thoughts, may be homicidal or suicidal

58. Periods of forgetfulness or memory problems

Q 47-58 Score: _______________

59. Trouble staying focused

60. Spaciness or feeling like you're in a fog

61. Overwhelmed by tasks of daily living

62. Feels tired, sluggish, or slow moving

63. Procrastination, failure to finish things

64. Chronic boredom

65. Loses things

66. Easily distracted

67. Foregetful

68. Poor planning skills

69. Difficulty expressing feelings

70. Difficulty expressing empathy for others

Q 59-70 Score: _______________

AMEN CLINIC Mood Disorder Questionnaire

For the following questions, check the answer that best applies to you. Answer each question as best you can.

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

... 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

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

Yes
No

... you felt much more self-confident than usual?

Yes
No

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

Yes
No

... you were much more talkative or spoke faster than usual?

Yes
No

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

Yes
No

... you were so easily distracted by things around you that you had trouble concentrating or staying on track?

Yes
No

... you had much more energy than usual?

Yes
No

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

Yes
No

... you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night?

Yes
No

... you were much more interested in sex than usual?

Yes
No

... you did things that were unusual for you or that other people might have thought were excessive, foolish or risky?

Yes
No

... spending money got you or your family in trouble?

Yes
No

If you checked YES to more than one of the above, have several of these ever happened during the same period of time? (Please check 1 response only.)

Yes
No

How much of a problem did any of these cause you--like being able to work; having family, money or legal troubles; getting into arguments or fights? (Please check 1 response only.)

No problem
Minor problem
Moderate problem
Serious problem

Have any of your blood relatives (i.e., children, siblings, parents, grandparents, aunts, uncles) had manic-depressive illness or bipolar disorder?

Yes
No

Has a health professional ever told you that you have manic-depressive illness or bipolar disorder?

Yes
No