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#2 NEW PATIENT- ADHD assessment
*Binge eating disorder assessment
*FOLLOW-UP FORM: Anxiety
*FOLLOW-UP FORM: Depression
MDQ follow-up
Medication renewal form
*FOLLOW-UP FORM: ADHD
Patient survey
MDQ follow-up
Name:
*
Date:
*
Has there ever been a period of time when you were not your usual self and...
1. 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
2. You were so irritable that you shouted at people and started fights or arguments?
*
Yes
No
3. You felt much more self-confident than usual?
*
Yes
No
4. You got much less sleep than usual and found you didn't really miss it?
*
Yes
No
5. You were much more talkative and spoke much faster than usual?
*
Yes
No
6. Thoughts raced through your head or you couldn't slow your mind down?
*
Yes
No
7. You were so easily distracted by things around you that you had trouble concentrating or staying on track?
*
Yes
No
8. You had much more energy than usual?
*
Yes
No
9. You were much more active or did many more things than usual?
*
Yes
No
10. You were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night?
*
Yes
No
11. You were much more interested in sex than usual?
*
Yes
No
12. You did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?
*
Yes
No
13. Spending money got you or your family into 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?
*
No problem
Minor problem
Moderate problem
Serious problem
Have any of your blood relatives (ie. 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
* Required field
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