Bipolar Disorder:

Bipolar disorder, previously called manic-depression, is characterized by extreme shifts in mood, energy, and behavior. People with this disorder may fluctuate between “up” periods (called manic episodes) and “down” periods (called depressive episodes.) Individuals may experience only some of the following symptoms at any given time.

In a manic episode, have you experienced any of the following?

  • Excessively good or euphoric mood
  • Racing thoughts and speech
  • Little need for sleep
  • Spending sprees or unusual behavior
  • Unusual distractibility

In a depressive episode, have you experienced any of the following?

  • Sad, anxious or empty mood
  • Feelings of hopelessness, guilt, or worthlessness
  • Loss of interest or pleasure in things once enjoyed
  • Changes in eating and sleeping habits
  • Thoughts of death or suicide

If you are experiencing any of the above symptoms, you may be suffering from bipolar disorder. Artemis Institute for Clinical Research is conducting a clinical trial of an investigational medication for the treatment of bipolar disorder. Qualified persons that participate in this research study may receive monetary compensation for time and travel, study-related medical evaluations, psychological assessments and investigational study drug at no cost.

If you would like to participate in this clinical study, please complete our optional self-assessment questionnaire below or call (858) 278-3647 for more information.

Bipolar Disorder Questionnaire

Although you will need a full screening by our medical staff to be accepted into this study, your answers to this questionnaire are important. Please take a moment to answer the following questions and tell us about yourself. Please expect to receive a call from us within one business day to discuss your potential participation in the study.

*Last Name

*First Name

*Phone Number

*Email Address

Zip Code

Best Time to Call:

 Morning Afternoon

Gender:
 Male Female

*How did you hear about Artemis Institute for Clinical Research?
 Google Yahoo Bing Yelp Kudzu MSN Facebook Twitter Facebook Ad Google Ad Craigslist Ad TV Radio San Diego Union Tribune San Diego Reader Other (please specify

Does anyone in your immediate family have any of the following? (Please check all that apply)
 Bipolar Disorder Psychosis Schizophrenia None of these

Please let us know which of the following symptoms you may be experiencing. (Please check all that apply)
Mania:
 Having racing thoughts or is talkative Having elated or euphoric moods Having little need for sleep Engaged in excessive spending or unusual behaviors Feeling distracted Feeling irritable Feeling impulsive

Depression:
 Feeling sad, hopeless or discouraged Trouble concentrating, remembering things or making decisions Feeling restless or irritable Feeling tired or having little energy Having difficulty getting started or performing everyday activities Not enjoying activities that normally give pleasure Changes in appetite or weight Feeling guilty, pessimistic about the future or like a failure

Have you been diagnosed with bipolar disorder by a doctor?
 Yes No

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