Self-Report Form for Mood Episodes (SRF-ME)

Self-Report Form for Mood Episodes (SRF-ME)
Name:__________________________ ID#: _______________ Clinician: __________________________ Date: _____________
Since your last appointment:
Has there been a period of time when you were feeling down or depressed most of the day, nearly everyday?
If Yes, Did it last as long as two weeks?
What about being a lot less interested in most things or unable to enjoy things you usually enjoy?
If Yes , Did it last as long as 2 weeks?
Has there been a period of time when your were feeling so good or so hyper people thought you were not
your normal self or you were so hyper you got in trouble?
If Yes, Was it more than just feeling good?
Did anyone say you were manic?
What about a period of time when you were so irritable that you would shout at people or start fights or arguments?
Have you experienced a major stress that you feel has caused your mood to change?
If Yes, describe:__________________________________________
Have you experienced other medical problems?
If Yes, describe:__________________________________________
Used additional psychiatric care/treatment ❑ Yes ❑ No
Other medical treatment ❑Yes ❑ No
Yes
Yes
Yes
Yes
No
No
No
No
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Yes
No
Onset of last menses __ __ / __ __ / __ __
Over the past 10 days how many days have you been/had…
…depressed most of the day ____ /10 Days
…unable to experience pleasure most of the day ____ /10 Days
…any period of abnormal mood elevation ____ /10 Days
… any period of abnormal irritability ____ /10 Days
…any period of abnormal anxiety ____ /10 Days
During the past week…
What is the least you have slept in any one day _____hrs
What is the most you have slept any one day _____hrs
Have you had: Panic Attacks ____
Binge/Purge ____
Headaches ____
Weight ____
Indicate your use of: Caffeine ___ cups/day
Nicotine ___ packs/day
Alcohol ___ drinks/week
Drugs ________
→ → → → →
FOR EACH ITEM RATE THIS WEEK
compared to your usual (when well)
Constant
and Severe
Sleep
Ability to enjoy pleasant things/usual interests
Self-confidence/self-esteem
Energy
Ability to concentrate
Distractibility
Appetite
Physical restlessness/agitation
Rate of speech or thoughts
Feel life isn’t worth living or suicidal thoughts
Talking
Racing thoughts
Making plans or getting new projects started
Behaviors others regard as excessive, foolish or risky
Decreased
→
Nearly
Every Day
Often
Rarely and/
or Mild
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WELL
❑ Normal
❑ Normal
❑ Normal
❑ Normal
❑ Normal
❑ None
❑ Normal
❑ None
❑ None
❑ None
❑ Normal
❑ None
❑ Normal
❑ None
→
Increased
Rarely and/
or Mild
Often
Nearly
Every Day
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Constant
and Severe
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Please complete for all medications used since your last visit
Medication
Total daily dose
Mg missed this week
______ Mg
______ Mg
______ Mg
______ Mg
______ Mg
______ Mg
______ Mg
______ Mg
______ Mg
______ Mg
______ Mg
______ Mg
______ Mg
______ Mg
______ Mg
______ Mg
© Gary Sachs, MD, 2002
Provided courtesy of CME Outfitters, LLC
Comments/adverse effects
❑ Check if no adverse effects
Permission for use granted by G. Sachs
Available for download at www.neuroscienceCME.com