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* 1. Patient Information

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* 2. Rate your MOOD for the past two weeks:

Sad - Depressed "Normal" Too Happy - Manic
i We adjusted the number you entered based on the slider’s scale.

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* 3. Rate your ANXIETY LEVEL for the past two weeks:

None Moderate Panic Attacks
i We adjusted the number you entered based on the slider’s scale.

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* 4. Tell us about your SLEEP pattern for the past week:

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* 5. Since your last appointment, has your WEIGHT:

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* 6. Have you taken your MEDICATIONS as prescribed?

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* 7. Are you experiencing any MEDICATION SIDE-EFFECTS?

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* 8. Do you think your MEDICATION needs to be ADJUSTED or CHANGED?

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* 9. Are you participating in COUNSELING or THERAPY?

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* 10. Have there been any CHANGES in your OVERALL HEALTH?

T