Skip to content
Askalot

← All Healthcare templates

Questionnaire template

Mood Highs and Lows Self-Reflection

A non-diagnostic reflection for adults on recent periods of high and low mood, their effects and support needs.

Preview

Healthcare · Mental health. All Healthcare templates

Questions in this template

Mood Changes Over the Past Year

  1. Thank you for taking part. These questions help you describe any periods of unusually high or low mood, so you can talk them through with a health professional.

  2. This is a self-reflection, not a diagnosis. Only a qualified clinician can assess whether mood changes are part of bipolar disorder or another condition.

  3. In the past 12 months, have you had periods lasting several days when you felt unusually energetic, elated or irritable, clearly different from your normal self?

    Choose one:

    • Yes
    • No
    • Not sure

  4. In the past 12 months, have you had periods of two weeks or longer when you felt low or lost interest in most things?

    Choose one:

    • Yes
    • No
    • Not sure

  5. How much does your mood usually change from one week to the next?

    Choose one:

    • Hardly at all
    • A little
    • Moderately
    • A lot
    • Extremely

Your High Periods

  1. During these high periods, did you notice any of the following?

    Condition: Only for those who reported high periods

    • Needing much less sleep than usual without feeling tired
    • Talking more or faster than usual
    • Thoughts racing from one idea to the next
    • Starting many new plans or projects at once
    • Spending money or taking risks in ways that are unusual for you
    • Feeling far more confident or important than usual

    For each row: choose one:

    • Yes
    • No

  2. How long does a high period usually last?

    Condition: Only for those who reported high periods

    Choose one:

    • A day or less
    • 2 to 3 days
    • 4 to 6 days
    • A week or longer

  3. How much trouble have these high periods caused you, for example at work, with money or in relationships?

    Condition: Only for those who reported high periods

    Choose one:

    • No problems
    • Minor problems
    • Moderate problems
    • Serious problems

Your Low Periods

  1. During these low periods, did you notice any of the following?

    Condition: Only for those who reported low periods

    • Feeling low for most of the day
    • Losing interest in things you normally enjoy
    • Feeling exhausted or slowed down
    • Sleeping much more or much less than usual
    • Feeling worthless or guilty
    • Finding it hard to concentrate or make decisions

    For each row: choose one:

    • Yes
    • No

  2. How much trouble have these low periods caused you in daily life?

    Condition: Only for those who reported low periods

    Choose one:

    • No problems
    • Minor problems
    • Moderate problems
    • Serious problems

  3. During low periods, have you had thoughts of harming yourself or of not wanting to be alive?

    Condition: Only for those who reported low periods

    Choose one:

    • Yes
    • No
    • Prefer not to say

  4. Thank you for telling us. Please speak to a doctor, a mental health professional or a crisis line soon; if you are in immediate danger, call your local emergency number.

Background and Support

  1. Has a parent, brother, sister or child of yours been diagnosed with bipolar disorder or another serious mood condition?

    Choose one:

    • Yes
    • No
    • Not sure

  2. Have you ever talked to a health professional about your mood swings?

    Choose one:

    • Yes
    • No

  3. Would you like information about where to get support?

    Choose one:

    • Yes
    • No

  4. Is there anything else about your mood that you would like to note before talking to a professional? (optional)

    Open answer