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Mental Health questionare for friends and family

Please answer the questions relative to how Toby has been presenting over the past month

0- none of the time

5-all of the time


over the past month Toby has...

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1

Been overly iritated or quick to anger

1 - 5 rating system only
2

Unmotivated

3

Sad for no good reason

4

Over sleeping

5

Over/Under eating

6

Lacking basic hygeine

7

overly pessimistic

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8

Reporting hallucinations

9

Appeared on edge or scared for no good reason

10

Had fast or unintelligible speach

11

Experiencing delusions

12

Shared strange or confusing thoughts

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13

Showed a consistent lack of empathy

14

Aggressive towards people/animals

15

Inceased impulsivity

16

Manipulating others

17

Grandiosity

18

Extreme boredom

19

Lack of remorse / faked remorse for actions

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20

Extreme mood swings

21

Splitting on others

splitting is when someone who has BPD rapidly changes their opinion on someone going from extreme love to extreme hate
22

Exercised thoughts of fear of people leaving

23

Self harmed

24

Reported turbulence in relationships

25

Going from one extreme mood to another within a short time period

26

Expressed feeling of emptiness and despair

27

Expressed thoughts of suicide

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28

Appeared overly happy or excited for a period longer than a week consistently

29

Extreme 'up' mood was followed by a period of depression that lasted at least a week

30

had a period of increased impulsivity

31

Increased drug/alcohol usage

32

fast paced speach

33

decreased sleep while in 'up' mood

34

Dilated pupils (not otherwise explained by lighting)

35

fantastical ideas and plans for large projects

36

While depressed there was oversleeping

37

loss of apetite

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The next questions will be in relation to Toby's appearence and behaviour

38

Lack of showering

39

Wore the same clothes multiple days in a row

40

Was late to plans and/or forgot about plans

41

forgetting items ie: wallet at home

42

had a messy room

43

Not texting back / dry responses

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Next will be yes or no questions :)

At any point were you concerned that Toby was...

44

Manic

45

Extremely paranoid

not in relation to being manic
46

In a depressive episode

47

Going to attempt suicide

48

Going to harm himself

49

Going to harm someone else

50

Hallucinating

Not in relation to being manic
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If you have had any other concerns about Toby please add them below :D

51

Other concerns

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