The Healing Center LLC
Bipolar Disorder Research Form
Name:
Address:
City:
State:
Zip:
Country:
Telephone:
Email Address:
Birth date and time:
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Place of birth:
Have you ever been diagnosed with symptoms of Unipolar or Depression? If so, When?
Have you ever been diagnosed with symptoms of Major Depressive Disorder? If so, when?
If female, do you experience Premenstrual Syndrome (PMS)? If so, how frequently? If not female, have or do first degree (parent/sibling/child) female members of your family report symptoms of Premenstrual Syndrome (PMS)?
Has a first degree family member (parent/sibling/child) been diagnosed with symptoms of unipolar depression, major depressive disorder or Premenstrual Syndrome (PMS)? If yes, please describe in detail.
Have you or a first degree relative (parent/sibling/child) been diagnosed as having bipolar disorder? If so, when, and under what circumstances?
Have you or a first degree relative ever utilized over the counter drugs, alcohol or recreational drugs to control moods, “mellow out”, etc. When did, or how often has this occurred?
Have friends, relatives, siblings, and/or spouses reported that usage of these substances temporarily improved your mood and/or behavior? Is there a pattern to this usage or behavior? Is it related to seasons or other variables? Please describe in detail.
Have you ever attempted to utilize prescription medication for depressive or bipolar symptoms but found it ineffective? If so, please describe in detail your experience and the months/years in your life when this has occurred.
Participants will be contacted for follow-up interviews for in-depth information as needed. Thank you for your participation in this research project.
