Mood Disorder Clinic Screen

From MindLinc Wiki

MOOD DISORDER CLINIC SCREEN

Name ____________________ MR# _______________ Date ________________

Physician _______________

RECENT HISTORY

Chart Diagnosis 0 BP1 0 BP2 0 Bipolar NOS 0 “Bipolar Mood Disorder”

Current Mood State ________________________

Most Recent Episode(s)

    Month/year, duration (days)			Month/year, duration (days)

0 Syndromal Mania/Mixed (7 days) ____¬_, _____ 0 Subsyndromal mania ____¬_, _____ 0 Syndromal Hypomania (4 days) ____¬_, _____ 0 Subsyndromal hypomania ____¬_, _____ 0 Syndromal Depression (14 days) ____¬_, _____ 0 Subsyndromal Depression ____¬_, _____

Current medications: ______________________________________________________

PRIOR HISTORY vvvvvv

Worst Manic Episode Month/year, duration (days) __________, ___________ Manic Symptoms present during worst episode 0 Euphoric/elated 0 Expansive 0 Irritable 0 Grandiose 0 Risk taking 0 Overly talkative 0 Pressured speech 0 Flight of ideas 0 Racing thoughts 0 Distractible 0 Decreased need for sleep 0 Increased goal-directed activity 0 Psychomotor restlessness 0 Psychosis

Evidence of Impairment during a single episode

0 Overspending 0 Sexual misconduct 0 Legal problems 0 Aggression 0 Work problems 0 Unplanned travel 0 Hospitalization

First Episode Age _______

Lifetime # manic episodes:____________ Lifetime # depressive episodes:______________

Pattern 0 DEM 0 DME 0 MED 0 MDE 0 MDMDMD

LIFETIME DIAGNOSIS

0 BP1 definite 0 BP1 possible/BP2 definite 0 BP2 possible (explain)__________________________________________ 0 BP NOS/Spectrum (explain)__________________________________________________ 0 3rd consecutive generation MI, SUD or suicide 0 Nonconsecutive but loaded pedigree 0 Any family history of BD 0 Early onset 0 Frequent, brief episodes 0 Reverse vegetative features 0 Psychosis 0 Postpartum onset 0 AD induced symptoms 0 Schizoaffective 0 Unipolar