lNAME of friend or relative _____________________________

YOUR NAME and relationship ______________________________

DATE _____________

The following questions may help determine which medication is appropriate for your friend or relative. Circle yes or no, as you go.
? Has there ever been a period of time when you noticed they were not their usual self and......they seemed to feel so good or so hyper that you thought YES

they werent their normal self, or they were so hyper they got into trouble? were so irritable that they shouted at people or started fights or arguments?YESNO...they acted much more self-confident than usual? YESNO...they got much less sleep than usual and seemed to not really miss it? YESNO...they were much more talkative or spoke faster than usual? YESNO...they had many ideas at once or their thoughts raced from topic to topic?YESNO...they were so easily distracted by things around them that you had trouble following their train of thought?
YES NO...they NO...they

seemed to have much more energy than usual?YESNO...they were much more active or did many more things than usual?YESNO...they were much more social or outgoing than usual; for example, telephoning friends in the middle of the night?
YES NO...they

were much more interested in sex than usual?YESNO...they did things that were unusual for them or that you thought were excessive, foolish, or risky?YESNO...they spent money to the point that it got them or their family into trouble?YESNO? If you checked YES to more than one of the above, have several of these ever happened during the same period of time?
YES

NO

How much of a problem did any of these cause like being unable to work; having family, money, or legal troubles; getting into arguments or fights?
MINOR PROBLEM MODERATE PROBLEM PROBLEM SERIOUS

NO PROBLEM

lNAME of friend or relative _________________________________ DATE _____________ YOUR NAME and relationship ______________________________ Instructions: Please read through the entire passage below before filling in any blanks. Some individuals notice that their mood and/or energy levels shift drastically from time to time . These individuals notice that, at times, their mood and/or energy level is very low, and at other times, very high . During their low phases, these individuals often feel a lack of energy; a need to stay in bed or get extra sleep; and little or no motivation to do things they need to do . They often put on weight during these periods . During their low phases, these individuals often feel blue, sad all the time, or depressed . Sometimes, during these low phases, they feel hopeless or even suicidal . Their ability to function at work or socially is impaired . Typically, these low phases last for a few weeks, but sometimes they last only a few days . Individuals with this type of pattern may experience a period of normal mood in between mood swings, during which their mood and energy level feels right and their ability to function is not disturbed . They may then notice a marked shift or switch in the way they feel . Their energy increases above what is normal for them, and they often get many things done they would not ordinarily be able to do . Sometimes, during these high periods, these individuals feel as if they have too much energy or feel hyper . Some individuals, during these high periods, may feel irritable, on edge, or aggressive . Some individuals, during these high periods, take on too many activities at once . During these high periods, some individuals may spend money in ways that cause them trouble . They may be more talkative, outgoing, or sexual during these periods . Sometimes, their behavior during these high periods seems strange or annoying to others . Sometimes, these individuals get into difficulty with co-workers or the police, during these high periods . Sometimes, they increase their alcohol or non-prescription drug use during these high periods . Now that you have read this passage, please check one of the following four boxes (consider their whole life when you answer, including recent times): This story fits my friend or relative very well, or almost perfectly 6 This story fits my friend or relative fairly well 4 This story fits my friend or relative to some degree, but not in most respect 2 This story does not really describe my friend or relative at all Now please go back and put a check after each sentence that definitely describes your friend or relative.