NCHH - BSDS Screener by Another for Patient

Screener to Assess for types of Mood

This is a HIPAA compliant form in which you are answering questions for and about another person at our request (Adapted from BSDS)
BSDS Calculation
1. The name of the person for whom you are completing this form.

First NameLast Name
2. Your Email address
example@example.com
3. Your Name & relationship to the person for whom you are completing this form.
4. The clinician (doctor, nurse practitioner or therapist) that asked you to fill out this form
Please read this paragraph completely, then answer the questions below:

Some individuals have mood and/or energy levels that shift drastically from time to time.

These individuals, at times, have mood and/or energy levels that are very low, and at other times, very high.

During their "low" phases, these individuals often feel a lack of energy; a need to stay in bed or get extra sleep; or have little or no motivation to do things they need to do.

These individuals can, often, put on weight during these periods.

During their low phases, these individuals can feel "blue", sad all the time, or even "depressed.

Sometimes, during these low phases, they feel hopeless or even suicidal. Their ability to function at work or socially can be impaired.

Typically, these low phases can last for a few weeks, but sometimes they last only a few days.

Individuals with this type of pattern may experience a period of "normal" mood in between mood swings, during which their mood and energy level can feel "right" and their ability to function is not disturbed.

They may then notice a marked shift or "switch" in the way they feel. Their energy increases above what is normal for them, and they often get many things done they would not ordinarily be able to do.

Sometimes, during these "high" periods, these individuals may feel as if they have too much energy or feel or act "hyper" or "very distracted.

Some individuals, during these high periods, may feel irritable, "on edge", or aggressive.

Some individuals, during these high periods, take on too many activities at once.

During these high periods, some individuals may spend money in ways that cause them trouble.

They may be more talkative, outgoing, or even more sexual during these periods Sometimes, their behavior during these high periods seems strange or annoying to others.

Sometimes, these individuals get into difficulty (arguments, disagreements, or even fights) with coworkers or the police, during these high periods.

Sometimes, these individuals can increase their alcohol or non-prescription/prescription drug use during these high periods.
Now that you have read the passage above, PLEASE check one of the following fourboxes about the person whom you are completing the form:*

This story fits the person very well, or almost perfectlyThis story fits the person fairly wellThis story fits the person to some degree, but not in most respectsThis story does not really describe the person at all
Now please select each sentence that definitely describes the person.*

Some individuals notice that their mood and/or energy levels shift drastically from time to timeThese individuals, at times, have mood and/or energy levels that are very low, and at other times, very high.During their "low" phases, these individuals often feel a lack of energy; a need to stay in bed or get extra sleep: or have little to no motivation to do things.These individuals can, often, put on weight during these periods.During their low phases, these individuals often feel "blue", sad all the time, or depressed.Sometimes, during these low phases, they feel hopeless or even suicidal. Their ability to function at work or socially can be impaired.Typically, these low phases last for a few weeks, but sometimes they last only a few days.Individuals with this type of pattern may experience a period of "normal" mood in between mood swings, during which their mood and energy level can feel "right" and their ability to function is not disturbed.They may then notice a marked shift or "switch" in the way they feel. Their energy increases above what is normal for them and they often get many things done they would not ordinarily be able to do.Sometimes, during these "high" periods, these individuals may feel as if they have too much energy or feel or act "hyper" or "very distracted.Some individuals, during these high periods, may feel irritable, "on edge", or aggressive.Some individuals, during these high periods, take on too many activities at once.During these high periods, some individuals may spend money in ways that cause them trouble.They may be more talkative, outgoing, or even more sexual during these periods.Sometimes, their behavior during these high periods seems strange or annoying to others.Sometimes, these individuals get into difficulty (arguments, disagreements, or even fights) with coworkers or the police, during these high periods.Sometimes, these individuals can increase their alcohol or non-prescription/prescription drug use duringthese high periods.NONE OF THESE DESCRIBE THE PEROSN FOR WHOM I AM COMPLETING THE FORM
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Screener to Assess for types of Mood