BIPOLAR DISORDER CHECK - IN QUESTIONNAIRE
This questionnaire is designed to help you or someone you care about monitor mood, behavior, and overall well-being. It can be used for regular check-ins to identify any early signs of mood changes.
1. Current Mood
• How would you rate your mood today on a scale of 1 to 5?
o (1 = Very low/depressed, 5 = Very high/elevated)
o
2. Sleep Patterns
• How many hours did you sleep last night?
o
• Did you have difficulty falling asleep or staying asleep? (Yes/No)
o
• Have you noticed any changes in your sleep patterns recently? (Yes/No)
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3. Energy Levels
• How would you describe your energy level today?
o ( ) Low ( ) Moderate ( ) High
• Have you experienced any unusual bursts of energy or fatigue? (Yes/No)
o
4. Appetite and Eating Habits
• Have you noticed any changes in your appetite or eating habits?
o ( ) Decreased appetite ( ) Increased appetite ( ) No change
• Are you eating regularly and healthily? (Yes/No)
o
5. Thought Patterns
• Have you had any racing thoughts or trouble focusing?
o ( ) Frequently ( ) Occasionally ( ) Not at all
• Have you experienced any negative or intrusive thoughts?
o ( ) Frequently ( ) Occasionally ( ) Not at all
6. Daily Activities
• Are you able to complete your daily activities as usual?
o ( ) Yes, with ease ( ) Yes, with difficulty ( ) No
• Have you lost interest in activities you usually enjoy? (Yes/No)
o
7. Social Interactions
• Have you been more or less social than usual lately?
o ( ) More social ( ) Less social ( ) No change
• Are you feeling connected to your support system? (Yes/No) o
8. Coping and Stress Management
• Have you been using healthy coping strategies to manage stress?
o ( ) Yes ( ) No
• Are you feeling overwhelmed or stressed more than usual? (Yes/No)
o
9. Medication and Treatment
• Are you taking your medication as prescribed? (Yes/No)
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• Have you noticed any side effects or changes in how you feel? (Yes/No)
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10. Overall Well - Being
• On a scale of 1 to 5, how would you rate your overall well-being today?
o (1 = Very poor, 5 = Excellent)