Symptom Evaluation Form

	Bipolar Disorder Symptom Evaluation Form

The following symptoms of Bipolar Disorder are listed as being typical. This information is being collected to determine the effectiveness of the product provided to you.

Please evaluate each symptom using the following scale:
0= Not at all 1= Just a little 2= Somewhat 3= Very much

Name :
Date :

Symptoms	Sun	Mon	Tues	Wed	Thurs	Fri	Sat
Feeling worthless, helpless or hopeless
Sleeping more or less than usual
Eating more or less than usual
Hard to concentrate or decide
Loss of interest in hobbies or activities
Avoiding other people
Overwhelming feelings of sadness
Loss of energy, feeling very tired
Thoughts of death or suicide
An excessively high or elated mood
Unreasonable optimism or poor judgment
Hyperactivity or racing thoughts
Talkativeness / rapid speech / incoherent
Irritability
Extremely short attention span
Rapid shifts to rage or sadness

Supplement dosage, sleep, and medication
Empower daily dosage (# of capsules)
Hours of sleep
Drug 1 daily dosage Name:
Drug 2 daily dosage Name:
Drug 3: daily dosage Name:
Drug 4: daily dosage Name:
Drug 5: daily dosage Name:

Comments





Please send completed forms to Truehope Nutritional Support Ltd. Ph:* 1-888-TRUEHOPE (1-888-878-3467) Fax: 1-888-752-7212 Email: sef@truehope.com Mail: P.O. Box 888, Raymond, Alberta, Canada, T0K 2S0 Copyright © 2002 Truehope Nutritional Support Ltd. Revised October 11, 2002