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Mood Disorder Questionnaire

screening tool for bipolar disorder

HTML icon MDQ.html — HTML, 11 kB (11347 bytes)

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>

<!-- CSS Script that removes textarea and textbox borders when printing ---(put this inbetween <header></header>)----------------->
<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>

<!-- The submit/print/reset buttons ------------------------------------------------------------->
<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>

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