Bipolar Research at IU























BIPOLAR SURVEY

The study of Bipolar Affective Disorder at Indiana University is looking for individuals who have a history of bipolar illness.  This screening form, which asks about your history of mood disorders, will help our researchers determine if you may meet the criteria for our study.  For individuals chosen for the study, each participant will be asked to complete a diagnostic interview, answer family history questions, and provide a small blood sample.  It is NOT necessary to live in Indiana to participate in this study.

Please note: This form is best viewed at a resolution of 1024x800 or greater.  Although it is unlikely that you will experience any problems responding to this form, certain non-standard browsers will not respond properly. If you experience any difficulties, (or if you are not using a forms-capable browser) you may email your interest in this study to: Indiana University Bipolar Study or call our researchers toll-free at 888-750-2201.

Please complete the information below about yourself.  Use the TAB key or mouse to move between fields, click with mouse to select yes or no choices.

First Name: Last Name
Date of Birth:    Month: Day: Year:
Address
City: State Zip:
Phone:
Email:
Have you ever had symptoms of severe mania? Yes No   Click for list of mania symptoms
Have you ever been hospitalized for mania? Yes No
Have you ever had symptoms of depression? Yes No   Click for list of depression symptoms
Please list any medications you take for mania or depression:
Do you have any children ages 12-21 years old? Yes No
          If you have children, list their initials and age below:
  Initials      Age
  1.    
  2.
  3.
  4.
Can we contact you about participating in this confidential study? Yes No

Other Relatives

Do you have other relatives who have a history of ANY mood disorders? Yes No

If yes, how many relatives?

Any other comments you would like to share with our research personnel regarding this study:


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Thank you for participating in our study.

Note: Some browsers will pop up a warning about sending this information over the internet.  This web site uses forms, which are more secure than regular e-mail messages.  In addition, your privacy is carefully guarded by our researchers.  If you would prefer not to use this form or e-mail, please call our researchers directly toll free at 888-750-2201.  You may also print this page and mail it to us at:

Bipolar Genetics Study

Indiana University School of Medicine
791 Union Drive
Indianapolis, IN  46202-4887
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Last updated: April 29, 2008.