Bipolar Disorder

Questionnaire

Please complete this questionnaire and return it to your therapist. This information will greatly assist your therapist in the correct diagnosis and treatment of your Bipolar Disorder.

Mania

When you are manic, what is it like when you are elated or excited?
 
 
 
 
 
 
 
 
 


When you are manic, what is it like when you are irritable or angry?
 
 
 
 
 
 
 
 
 


When you are manic, what is it like to be grandiose (having boundless self-confidence)?
 
 
 
 
 
 
 
 
 


When you are manic, what is it like not to need sleep?
 
 
 
 
 
 
 
 
 


When you are manic, what is it like to have pressured speech (constant talking)?
 
 
 
 
 
 
 
 
 


When you are manic, what is it like to have racing thoughts?
 
 
 
 
 
 
 
 
 


When you are manic, what is it like to be very distractible?
 
 
 
 
 
 
 
 
 


When you are manic, what is it like to be excessively active (constantly on the go)?
 
 
 
 
 
 
 
 
 


When you are manic, what is it like to engage in reckless pleasurable activities (e.g., buying sprees)?
 
 
 
 
 
 
 
 
 


Depression

When you are depressed, what is it like to feel depressed, sad, or empty?
 
 
 
 
 
 
 
 
 


When you are depressed, what is it like to have almost no interest or pleasure in your usual activities?
 
 
 
 
 
 
 
 
 


When you are depressed, what is it like to abnormally lose or gain weight?
 
 
 
 
 
 
 
 
 


When you are depressed, what is it like to sleep too little or too much?
 
 
 
 
 
 
 
 
 


What is it like to be physically agitated by your depression? Or the opposite, what is it like to be physically slowed by your depression (moving slower, talking slower, thinking slower)?
 
 
 
 
 
 
 
 
 


When you are depressed, what is it like to be excessively fatigued?
 
 
 
 
 
 
 
 
 


When you are depressed, what is it like to feel worthless or excessively guilty?
 
 
 
 
 
 
 
 
 


When you are depressed, what is it like to have poor concentration and to be indecisive?
 
 
 
 
 
 
 
 
 


When you are depressed, what is like to have suicidal thoughts?
 
 
 
 
 
 
 
 
 


Medications

What is it like to be on medications for your Bipolar Disorder?
 
 
 
 
 
 
 
 
 


How effective have medications been for treating your Bipolar Disorder?
Answer only if you were on this drug: POOR FAIR GOOD EXCELLENT
Lithium        
Valproate/Divalproex        
Carbamazepine        
Lamotrigine        
Clonazepam        
* Chlorpromazine (Largactil, Thorazine)        
* Flupenthixol (Fluanxol)        
* Haloperidol (Haldol)        
* Olanzapine (Zyprexa)        
* Perphenazine (Etrafon, Trilafon)        
* Risperidone (Risperdal)        
* Another Antipsychotic (other than above)       
Antidepressants        

What is it like to be on Lithium?
 
 
 
 
 
 
 
 
 


What is it like to be on Valproate/Divalproex?
 
 
 
 
 
 
 
 
 


What is it like to be on Carbamazepine?
 
 
 
 
 
 
 
 
 


What is it like to be on Lamotrigine?
 
 
 
 
 
 
 
 
 


What is it like to be on Clonazepam?
 
 
 
 
 
 
 
 
 


What is it like to be on Chlorpromazine (Largactil, Thorazine)?
 
 
 
 
 
 
 
 
 


What is it like to be on Flupenthixol (Fluanxol)?
 
 
 
 
 
 
 
 
 


What is it like to be on Haloperidol (Haldol)?
 
 
 
 
 
 
 
 
 


What is it like to be on Olanzapine (Zyprexa)?
 
 
 
 
 
 
 
 
 


What is it like to be on Perphenazine (Etrafon, Trilafon)?
 
 
 
 
 
 
 
 
 


What is it like to be on Risperidone (Risperdal)?
 
 
 
 
 
 
 
 
 


What is it like to be on an antipsychotic medication (other than those listed above)? [Please name this antipsychotic medication]
 
 
 
 
 
 
 
 
 


What is it like to be on an antidepressant medication?
 
 
 
 
 
 
 
 
 


What other medications have helped you?
 
 
 
 
 
 
 
 
 


What medications had the most side-effects?
Answer only if you were on this drug: POOR
(Severe Side-Effects)
FAIR
(Moderate Side-Effects)
GOOD
(Mild Side-Effects)
EXCELLENT
(No Side-Effects)
Lithium        
Valproate/Divalproex       
Carbamazepine        
Lamotrigine        
Clonazepam        
* Chlorpromazine (Largactil, Thorazine)        
* Flupenthixol (Fluanxol)        
* Haloperidol (Haldol)        
* Olanzapine (Zyprexa)        
* Perphenazine (Etrafon, Trilafon)        
* Risperidone (Risperdal)        
* Another Antipsychotic (other than above)       
Antidepressants        

Psychotherapy

What was it like to be in psychotherapy (counselling) for Bipolar Disorder?
 
 
 
 
 
 
 
 
 


What type of psychotherapy helped you the most?
Answer only if you had therapy from this source: POOR FAIR GOOD EXCELLENT
From psychiatrist        
From psychologist        
From family doctor        
From other professional        
From self-help group        
Other (please state):

       

What was it about psychotherapy that helped you the most?
 
 
 
 
 
 
 
 
 


What was it about psychotherapy that hindered your recovery (if this happened)?
 
 
 
 
 
 
 
 
 


Hospitalization

What is it like to be hospitalized?
 
 
 
 
 
 
 
 
 


How many times have you been hospitalized?
 
 
 
 
 
 
 
 
 


Do you fear going to the hospital?
 
 
 
 
 
 
 
 
 



Employment

What is your current employment status (please circle)?

How has your illness affected your employment status?
 
 
 
 
 
 
 
 
 



Friendships

How many friends do you have that you can confide in (please circle):

How has your illness affected your friendships?
 
 
 
 
 
 
 
 
 


How can your family/friends help you recover?
 
 
 
 
 
 
 
 
 



Marriage

What is your current marital status (please circle):

How has your illness affected your marriage?
 
 
 
 
 
 
 
 
 


Parenting

How many children do you have?
 
 
 
 
 
 
 
 
 


How has your illness affected your parenting?
 
 
 
 
 
 
 
 
 


Recreation

How has your illness affected your leisure time?
 
 
 
 
 
 
 
 
 



What Helped The Most?

(Medication? Social Supports?)
 
 
 
 
 
 
 
 
 


What Hindered Recovery The Most?

(Alcohol? Not taking medication?)
 
 
 
 
 
 
 
 
 


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