Mood Disorder Assessment

     

Demographic Information

      Name:       Age:       Gender:       History of mood disorders in family:    

     

Major Depressive Disorder

      Depressed mood most of the day       Loss of interest or pleasure       Weight/appetite changes       Sleep disturbances       Fatigue or loss of energy       Feelings of worthlessness or guilt       Difficulty concentrating       Thoughts of death or suicide       Duration of symptoms:       Severity:                   None           Mild           Moderate           Severe                     Functional impairment:                   None           Mild           Moderate           Severe                  

     

Bipolar I Disorder

      Elevated or irritable mood       Decreased need for sleep       More talkative than usual       Racing thoughts       Distractibility       Increased goal-directed activity       Risky behavior       Duration of symptoms:       Severity:                   None           Mild           Moderate           Severe                     Functional impairment:                   None           Mild           Moderate           Severe                  

     

Bipolar II Disorder

      Periods of elevated mood       Periods of depression       Changes in sleep or energy       Impulsivity or poor judgment       Duration of symptoms:       Severity:                   None           Mild           Moderate           Severe                     Functional impairment:                   None           Mild           Moderate           Severe                  

     

Cyclothymic Disorder

      Mood swings lasting 2+ years       Periods of hypomanic symptoms       Periods of depressive symptoms       Duration of symptoms:       Severity:                   None           Mild           Moderate           Severe                     Functional impairment:                   None           Mild           Moderate           Severe                  

     

Persistent Depressive Disorder (Dysthymia)

      Depressed mood for 2+ years       Poor appetite or overeating       Insomnia or hypersomnia       Low energy or fatigue       Low self-esteem       Poor concentration       Feelings of hopelessness       Duration of symptoms:       Severity:                   None           Mild           Moderate           Severe                     Functional impairment:                   None           Mild           Moderate           Severe                  

     

Risk Assessment

      Suicidal thoughts       Self-harm       Substance abuse       Aggressive behavior