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Bipolar Survey Questions + Sample Questionnaire Template

Bipolar survey template consists of questions that help a medical professional understand whether an individual is showing symptoms of bipolar disorder. This is a self-explanatory questionnaire that even an individual can use to analyze his/her state of mind. This sample survey template can be customized and a number of questions can be added to suit the need of the researcher.

Bipolar disorder is a brain disorder that results in unusual shifts in moods, activity level, quality of work, sleeping pattern and more. An individual who is experiencing bipolar disorder can be extremely happy at one moment and extremely sad the next second. The variations are extreme and irrational. Timely and proper diagnosis can help get treatment in time and lead to a healthy and productive life.

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1. Please select your gender

Male

Female

2. Please select your age

Under 18

18-24

25-34

35-44

45-54

55-64

Above 64

3. Please select your ethnicity

Hispanic or Latino

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

Caucasian or White

Multiracial

Other

Prefer not to say

4. Please select the most appropriate answer

	Never	Rarely	Sometimes	Often	Very Often
At times I am much more talkative than usual	Never	Rarely	Sometimes	Often	Very Often

At times I am much more active than usual	Never	Rarely	Sometimes	Often	Very Often

I get into a mood where I feel jumpy and irritated	Never	Rarely	Sometimes	Often	Very Often

There are times when I have felt happy and sad at the same time	Never	Rarely	Sometimes	Often	Very Often

My self-confidence ranges from great to self-doubt to overconfidence all at the same time	Never	Rarely	Sometimes	Often	Very Often

In recent times there has been great variation in the quality and standard of my work	Never	Rarely	Sometimes	Often	Very Often

For no specific reasons I get angry and hostile	Never	Rarely	Sometimes	Often	Very Often

At times I am mentally dull and other times I am quick and sharp	Never	Rarely	Sometimes	Often	Very Often

I constantly keep forgetting names, words, places, locations etc.	Never	Rarely	Sometimes	Often	Very Often

At times I am greatly interested in being around people and other times I want to be left alone	Never	Rarely	Sometimes	Often	Very Often

5. Over the last 3 weeks, how often have you been bothered by the following:

	Not at all	Several days	More than half the days	Nearly everyday
No interest or pleasure in doing things	Not at all	Several days	More than half the days	Nearly everyday

Trouble falling asleep, staying asleep or sleeping way too much	Not at all	Several days	More than half the days	Nearly everyday

Feeling tired or having very little energy	Not at all	Several days	More than half the days	Nearly everyday

Eating too less or eating way too much	Not at all	Several days	More than half the days	Nearly everyday

Trouble concentrating on things, such as reading, watching television etc.	Not at all	Several days	More than half the days	Nearly everyday

Thoughts of hurting yourself or harming yourself in any way	Not at all	Several days	More than half the days	Nearly everyday

use this free template

Bipolar Survey Questions + Sample Questionnaire Template

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