Mood Disorder Questionnaire
screening tool for bipolar disorder
MDQ.html
—
HTML,
11Kb
File contents
<html>
<title>Mood Disorder Questionnaire</title>
<head>
<style type="text/css">
p.title{
text-transform: uppercase;
font-size: 16;
font-family: Arial;
font-weight: bolder;
text-align: left;
color: black;
}
p.heading{
font-weight: bolder;
text-decoration: underline;
}
td.heading1{
font-size: 12;
font-family: Arial;
font-weight: bold;
text-align: left;
vertical-align: top;
color: white;
background:black ;
border-width: 1;
}
td.heading2{
font-size: 12;
font-family: Arial;
font-weight: bold;
text-align: left;
vertical-align: top;
color: white;
background: #444444;
border-width: 1;
}
tr.odd{
background-color: #ffffff;
}
tr.even{
background-color: #dddddd;
}
td.question{
font-size: 12;
font-family: Arial;
font-weight: normal;
text-align: left;
vertical-align: top;
color: black;
border-width: 1;
}
td.answer{
font-size: 12;
font-family: Arial;
font-weight: normal;
text-align: center;
vertical-align: top;
color: black;
border-width: 1;
}
td.normaltext{
width: 100%;
font-size: 12;
font-family: Arial;
font-weight: normal;
text-align: left;
vertical-align: top;
color: black;
background-color: white;
border-width: 0;
}
input.formtext{
width: 100%;
height: 100%;
font-size: 12;
font-family: Arial;
font-weight: normal;
text-align: left;
vertical-align: top;
color: black;
background-color: white;
border-width: 1;
border-style: solid;
}
textarea.formtext{
width: 100%;
height: auto;
font-size: 12;
font-family: Arial;
font-weight: normal;
text-align: left;
vertical-align: top;
color: black;
background-color: white;
border-width: 1;
border-style: solid;
}
</style>
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<style type="text/css" media="print">
div.DoNotPrint {
display: none;
}
input.noborder {
border : 0px;
background: transparent;
}
textarea.noborder {
scrollbar-3dlight-color: transparent;
scrollbar-3dlight-color: transparent;
scrollbar-arrow-color: transparent;
scrollbar-base-color: transparent;
scrollbar-darkshadow-color: transparent;
scrollbar-face-color: transparent;
scrollbar-highlight-color: transparent;
scrollbar-shadow-color: transparent;
scrollbar-track-color: transparent;
background: transparent;
overflow: hidden;
//scrollbar : none;
border : 0px;
}
</style>
<!-- ----------------------------------------------------------------------------------------- -->
<script type="text/javascript" language="javascript">
function getCheckedValue(radioObj) {
if(!radioObj)
return parseInt(0);
var radioLength = radioObj.length;
if(radioLength == undefined)
if(radioObj.checked)
return parseInt(radioObj.value);
else
return parseInt(value);
for(var i = 0; i < radioLength; i++) {
if(radioObj[i].checked) {
return parseInt(radioObj[i].value);
}
}
return parseInt(0);
}
function totalScore(){
var i = 0;
i += getCheckedValue(document.Form.Q1a);
i += getCheckedValue(document.Form.Q1b);
i += getCheckedValue(document.Form.Q1c);
i += getCheckedValue(document.Form.Q1d);
i += getCheckedValue(document.Form.Q1e);
i += getCheckedValue(document.Form.Q1f);
i += getCheckedValue(document.Form.Q1g);
i += getCheckedValue(document.Form.Q1h);
i += getCheckedValue(document.Form.Q1i);
i += getCheckedValue(document.Form.Q1j);
i += getCheckedValue(document.Form.Q1k);
i += getCheckedValue(document.Form.Q1l);
i += getCheckedValue(document.Form.Q1m);
var j = 0;
j += getCheckedValue(document.Form.Q2);
var k = 0;
k += getCheckedValue(document.Form.Q3);
if ( (i >= 7) && j && k){
document.getElementById('MDQResult').value = "Positive Screen for bipolar disorder";
}else{
document.getElementById('MDQResult').value = "Negative Screen for bipolar disorder";
}
}
</script>
</head>
<body>
<form method="post" action="" name="Form">
<p class="title">
Mood Disorder Questionnaire
</p>
<div name="demographics">
<table width="800">
<tr>
<td class="heading1" width=25%>Patient name</td>
<td class="normaltext" width=75%><input class="formtext" name="PatientName" type="text" oscarDB=patient_name>
</tr>
<tr>
<td class="heading1">Date:</td>
<td class="normaltext"><input class="formtext" name="TodaysDate" type="text" oscarDB=today>
</tr>
</table>
</div>
<br>
<div name="Questionnaire">
<table width="800">
<tr>
<td class="heading2" width=40%>1. Has there ever been a period of time when you were not your usual self and...</td>
<td class="heading2" width=15%>Yes</td>
<td class="heading2" width=15%>No</td>
</tr>
<tr class="odd">
<td class="question"> ...you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble?</td>
<td class="answer"><input type="radio" name="Q1a" value="1"></td>
<td class="answer"><input type="radio" name="Q1a" value="0"></td>
</tr>
<tr class="even">
<td class="question">...you were so irritable that you shouted at people or started fights or arguments</td>
<td class="answer"><input type="radio" name="Q1b" value="1"></td>
<td class="answer"><input type="radio" name="Q1b" value="0"></td>
</tr>
<tr class="odd">
<td class="question">...you felt much more self-confident than usual?</td>
<td class="answer"><input type="radio" name="Q1c" value="1"></td>
<td class="answer"><input type="radio" name="Q1c" value="0"></td>
</tr>
<tr class="even">
<td class="question">...you got much less sleep than usual and found you didn't really miss it?</td>
<td class="answer"><input type="radio" name="Q1d" value="1"></td>
<td class="answer"><input type="radio" name="Q1d" value="0"></td>
</tr>
<tr class="odd">
<td class="question">...you got much more talkative or spoke much faster than usual?</td>
<td class="answer"><input type="radio" name="Q1e" value="1"></td>
<td class="answer"><input type="radio" name="Q1e" value="0"></td>
</tr>
<tr class="even">
<td class="question">...thoughts raced through your head or you couldn't slow your mind down?</td>
<td class="answer"><input type="radio" name="Q1f" value="1"></td>
<td class="answer"><input type="radio" name="Q1f" value="0"></td>
</tr>
<tr class="odd">
<td class="question">...you were so easily distracted by things around you that you had trouble concentrating or staying on track?</td>
<td class="answer"><input type="radio" name="Q1g" value="1"></td>
<td class="answer"><input type="radio" name="Q1g" value="0"></td>
</tr>
<tr class="even">
<td class="question">...you had much more energy than usual?</td>
<td class="answer"><input type="radio" name="Q1h" value="1"></td>
<td class="answer"><input type="radio" name="Q1h" value="0"></td>
</tr>
<tr class="odd">
<td class="question">...you were much more active or did many more things than usual?</td>
<td class="answer"><input type="radio" name="Q1i" value="1"></td>
<td class="answer"><input type="radio" name="Q1i" value="0"></td>
</tr>
<tr class="even">
<td class="question">...you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night?</td>
<td class="answer"><input type="radio" name="Q1j" value="1"></td>
<td class="answer"><input type="radio" name="Q1j" value="0"></td>
</tr>
<tr class="odd">
<td class="question">...you were much more interested in sex than usual?</td>
<td class="answer"><input type="radio" name="Q1k" value="1"></td>
<td class="answer"><input type="radio" name="Q1k" value="0"></td>
</tr>
<tr class="even">
<td class="question">...you did things that were unusual for you or that other people might hvae thought were excessive, foolish, or risky?</td>
<td class="answer"><input type="radio" name="Q1l" value="1"></td>
<td class="answer"><input type="radio" name="Q1l" value="0"></td>
</tr>
<tr class="odd">
<td class="question">...spending money got you or your family into trouble?</td>
<td class="answer"><input type="radio" name="Q1m" value="1"></td>
<td class="answer"><input type="radio" name="Q1m" value="0"></td>
</tr>
<tr class="even">
<td class="heading2" width=40%>2. If you checked YES to more than one of the above, have several of these ever happened during the same period of time?</td>
<td class="heading2" width=15%>Yes</td>
<td class="heading2" width=15%>No</td>
</tr>
<tr class="odd">
<td class="question"></td>
<td class="answer"><input type="radio" name="Q2" value="1"></td>
<td class="answer"><input type="radio" name="Q2" value="0"></td>
</tr>
<tr>
<td class="heading2" colspan="3">3. How much of a problem did any of these cause you - like being unable to work; having family, money or legal troubles; getting into arguments or fights?</td>
</tr>
<tr>
<td colspan="3">
<table width="100%">
<tr>
<td class="answer"><input type="radio" name="Q3" value="0">No Problem</td>
<td class="answer"><input type="radio" name="Q3" value="0">Minor Problem</td>
<td class="answer"><input type="radio" name="Q3" value="1">Moderate Problem</td>
<td class="answer"><input type="radio" name="Q3" value="1">Serious Problem</td>
</tr>
</table>
</td>
</tr>
<tr>
<td class="heading2" width=40%>4. Have any of your blood relatives (i.e. children, siblings, parents, grandparents, aunts, uncles) had manic-depressive illness or bipolar disorder?</td>
<td class="heading2" width=15%>Yes</td>
<td class="heading2" width=15%>No</td>
</tr>
<tr class="odd">
<td class="question"></td>
<td class="answer"><input type="radio" name="Q4" value="1"></td>
<td class="answer"><input type="radio" name="Q4" value="0"></td>
</tr>
<tr>
<td class="heading2" width=40%>5. Has a health professional ever told you that you have manic-depressive illness or bipolar disorder</td>
<td class="heading2" width=15%>Yes</td>
<td class="heading2" width=15%>No</td>
</tr>
<tr class="odd">
<td class="question"></td>
<td class="answer"><input type="radio" name="Q5" value="1"></td>
<td class="answer"><input type="radio" name="Q5" value="0"></td>
</tr>
</table>
<br>
<table width="800">
<tr>
<td><input type="button" onclick="totalScore()" value="Calculate"></td>
</tr>
<tr>
<td><input type="text" style="width:800px;" name="MDQResult" id="MDQResult"></td>
</tr>
</table>
</div>
<br>
<br>
<br>
<br>
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<div name="FunctionButtons" class="DoNotPrint">
<table>
<tr>
<td class="subjectline">
Subject: <input name="subject" size="40" type="text">
<input value="Submit" name="SubmitButton" type="submit">
<input value="Reset" name="ResetButton" type="reset">
<input value="Print" name="PrintButton" onclick="javascript:window.print()" type="button">
</td>
</tr>
</table>
</div>
</form>
<!-- ------End of submit/print/reset buttons----------------------------------------------------->
</body>
</html>
