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Bipolar Checklist

During your lifetime, have you ever experienced any of the following?

MANIA
Elated, expansive mood	Yes	No
Irritable mood	Yes	No
Inflated self-esteem or grandiosity	Yes	No
Decreased need for sleep	Yes	No
Talkativeness	Yes	No
Flight of ideas or racing thoughts	Yes	No
Distractibility	Yes	No
Increase in goal-directed activity	Yes	No
Excessive involvement in pleasurable activities that have a high potential for painful consequences	Yes	No
Impulsivity	Yes	No
Excessive spending	Yes	No

DEPRESSION
Periods of depression with sadness, loneliness and hopelessness	Yes	No
Loss of interest or pleasure in activities	Yes	No
Changes in weight or appetite	Yes	No
Feeling of guilt or worthlessness	Yes	No
Trouble concentrating or remembering things	Yes	No
Trouble making decisions	Yes	No
Fatigue or loss of energy	Yes	No
Thoughts of death or suicide	Yes	No
Tendency to isolate	Yes	No

If you have checked three or more symptoms under "Mania" and these symptoms were disruptive to your life, you may have had a manic episode.

If you have checked three or more symptoms under "Depression", you may have had a depressive episode.

If, in your lifetime, you have experienced a manic and a depressive episode, you may have Bipolar Disorder.

From time to time we may study Bipolar Disorder and may seek individuals to participate in such studies of investigational and well known medications for Bipolar Disorder. If you are selected, all research-related care and study medications will be provided at no cost.

You may contact Summit Research Network by calling (206) 292-CARE (2273) to learn more about current and pending studies.

All information you may provide is stored in a secure site, and cannot be released to any third party without your written and signed authorization.

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