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PHQ9

This is a form for recording a PHQ9 questionnaire . It is a standalone form ie it doesn't require an image file to be uploaded with it. Contributed by Shelter Lee, Crossroads Family Practice, Chilliwack, BC.

HTML icon PHQ9.html — HTML, 12 kB (12561 bytes)

File contents

<html>
<title>PHQ-9</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.PHQ9Form.Q1);
	i += getCheckedValue(document.PHQ9Form.Q2);
	i += getCheckedValue(document.PHQ9Form.Q3);
	i += getCheckedValue(document.PHQ9Form.Q4);
	i += getCheckedValue(document.PHQ9Form.Q5);
	i += getCheckedValue(document.PHQ9Form.Q6);
	i += getCheckedValue(document.PHQ9Form.Q7);
	i += getCheckedValue(document.PHQ9Form.Q8);
	i += getCheckedValue(document.PHQ9Form.Q9);
	// i += getCheckedValue(document.PHQ9Form.Q10); 

	document.PHQ9Form.PHQ9Score.value = i;
	if (i<=4){
		document.getElementById("minimal").style.background='yellow';
		document.getElementById("mild").style.background='white';
		document.getElementById("moderate").style.background='white';
		document.getElementById("severe").style.background='white';
	}
	else if (i>=5 && i<=14){
		document.getElementById("minimal").style.background='white';
		document.getElementById("mild").style.background='yellow';
		document.getElementById("moderate").style.background='white';
		document.getElementById("severe").style.background='white';
	}
	else if (i>=15 && i<=19){
		document.getElementById("minimal").style.background='white';
		document.getElementById("mild").style.background='white';
		document.getElementById("moderate").style.background='yellow';
		document.getElementById("severe").style.background='white';
	}
	else{
		document.getElementById("minimal").style.background='white';
		document.getElementById("mild").style.background='white';
		document.getElementById("moderate").style.background='white';
		document.getElementById("severe").style.background='yellow';

	}

}
</script>


</head>

<body>
<form method="post" action="" name="PHQ9Form">

<p class="title">
	Patient Health Questionnaire (PHQ-9)
</p>


<div name="demographics">
<table width="100%">
	<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="100%">

	<tr>
		<td class="heading2" width=40%>A. Over the last 2 weeks, how often have you been bothered by any of the following problems?</td>
		<td class="heading2" width=15%>Not at all (0)</td>
		<td class="heading2" width=15%>Several days (1)</td> 
		<td class="heading2" width=15%>More than half the days (2)</td>
		<td class="heading2" width=15%>Nearly every day (3) </td>
	</tr>
	<tr class="odd">
		<td class="question"> Q1. Little interest or pleasure in doing things</td>
		<td class="answer"><input type="radio" name="Q1" value="0"></td>
		<td class="answer"><input type="radio" name="Q1" value="1"></td>
		<td class="answer"><input type="radio" name="Q1" value="2"></td>
		<td class="answer"><input type="radio" name="Q1" value="3"></td>
	</tr>
	<tr class="even">
		<td class="question">Q2. Feeling down, depressed, or hopeless</td>
		<td class="answer"><input type="radio" name="Q2" value="0"></td>
		<td class="answer"><input type="radio" name="Q2" value="1"></td>
		<td class="answer"><input type="radio" name="Q2" value="2"></td>
		<td class="answer"><input type="radio" name="Q2" value="3"></td>
	</tr>
	<tr class="odd">
		<td class="question">Q3. Trouble falling or staying asleep, or sleeping too much</td>
		<td class="answer"><input type="radio" name="Q3" value="0"></td>
		<td class="answer"><input type="radio" name="Q3" value="1"></td>
		<td class="answer"><input type="radio" name="Q3" value="2"></td>
		<td class="answer"><input type="radio" name="Q3" value="3"></td>
	</tr>
	<tr class="even">
		<td class="question">Q4. Feeling tired or having little energy</td>
		<td class="answer"><input type="radio" name="Q4" value="0"></td>
		<td class="answer"><input type="radio" name="Q4" value="1"></td>
		<td class="answer"><input type="radio" name="Q4" value="2"></td>
		<td class="answer"><input type="radio" name="Q4" value="3"></td>
	</tr>
	<tr class="odd">
		<td class="question">Q5. Poor appetitie or overeating</td>
		<td class="answer"><input type="radio" name="Q5" value="0"></td>
		<td class="answer"><input type="radio" name="Q5" value="1"></td>
		<td class="answer"><input type="radio" name="Q5" value="2"></td>
		<td class="answer"><input type="radio" name="Q5" value="3"></td>
	</tr>
	<tr class="even">
		<td class="question"> Q6. Feeling bad about yourself or that you are a failure or have let yourself or your family down</td>
		<td class="answer"><input type="radio" name="Q6" value="0"></td>
		<td class="answer"><input type="radio" name="Q6" value="1"></td>
		<td class="answer"><input type="radio" name="Q6" value="2"></td>
		<td class="answer"><input type="radio" name="Q6" value="3"></td>
	</tr>
	<tr class="odd">
		<td class="question">Q7. Trouble concentrating on things, such as reading the newspaper or watching television</td>
		<td class="answer"><input type="radio" name="Q7" value="0"></td>
		<td class="answer"><input type="radio" name="Q7" value="1"></td>
		<td class="answer"><input type="radio" name="Q7" value="2"></td>
		<td class="answer"><input type="radio" name="Q7" value="3"></td>
	</tr>
	<tr class="even">
		<td class="question">Q8. Moving or speaking so slowly that other people could have noticed. Or the opposite being so fidgety or restless that you have been moving around a lot more than usual</td>
		<td class="answer"><input type="radio" name="Q8" value="0"></td>
		<td class="answer"><input type="radio" name="Q8" value="1"></td>
		<td class="answer"><input type="radio" name="Q8" value="2"></td>
		<td class="answer"><input type="radio" name="Q8" value="3"></td>
	</tr>
	<tr class="odd">
		<td class="question">Q9. Thoughts that you would be better off dead, or of hurting yourself in some way</td>
		<td class="answer"><input type="radio" name="Q9" value="0"></td>
		<td class="answer"><input type="radio" name="Q9" value="1"></td>
		<td class="answer"><input type="radio" name="Q9" value="2"></td>
		<td class="answer"><input type="radio" name="Q9" value="3"></td>
	</tr>

</table>
<br>
<table width="100%" class="DoNotPrint">

	<tr>
		<td class="heading2" width=40%>B. If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?</td>
		<td class="answer" width=15%><input type="radio" name="Q10" value="Not difficult at all">Not difficult at all</td>
		<td class="answer" width=15%><input type="radio" name="Q10" value="Somewhat difficult">Somewhat difficult</td> 
		<td class="answer" width=15%><input type="radio" name="Q10" value="Very difficult">Very difficult</td>
		<td class="answer" width=15%><input type="radio" name="Q10" value="Extremely difficult">Extremely difficult</td>
	</tr>
</table>



<table>
<tr>
	<td><input type="button" onclick="totalScore()" value="Calculate Total Score"></td>
	<td><input type="text" name="PHQ9Score" size="10" value=""></td>
</tr>
</table>
</div>


<br>
<br>


<div name="Instructions" class="DoNotPrint">
<table>
<tr>
	<td class="heading2">Instructions - How to Score the PHQ-9</td>
</tr>
<tr>
	<td class="normaltext">
		<p class="heading">Major depressive disorder is suggested if:</p>
		<ul>
			<li>of the 9 items, 5 or more are checked as at least 'more than half the days'
			<li>either Q1 or Q2 is positive, that is at least 'more than half the days'
		</ul>
	</td>
</tr>
<tr>
	<td class="normaltext">
		<p class="heading">Other depressive syndrome is suggested if:</p>
		<ul>
			<li>of the 9 items, Q1, Q2, or Q3 is checked as at least 'more than half the days'
			<li>either item Q1 or Q2 is positive, that is, at least 'more than half the days'
		</ul>
	</td>
</tr>
<tr>
	<td>
		<p>Also, PHQ-9 scores can be used to plan and monitor treatment.  To score the instrument, tally each response by the number value under the answer headings, (not at all=0, several days=1, more than half the days=2, and nearly everyday=3).  Add the numbers together to total the score on the bottom of the questionnaire.  Interpret the score by using the guide listed below.</p>

	</td>
</tr>
<tr>
	<td>
		<table>
			<tr>
				<td class="heading2">Score</td>
				<td class="heading2">Action</td>
			</tr>
			<tr id="minimal">
				<td>0-4</td>
				<td>The score suggests the patient may not need depression treatment</td>
			</tr>
			<tr id="mild">
				<td>5-14</td>
				<td>Mild major depressive disorder.  Physician uses clinical judgement about treatment, based on patient's duration of symptoms and functional impairement</td>
			</tr>
			<tr id="moderate">
				<td> 15-19</td>
				<td>Moderate major depressive disorder.  Warrants treatment for depression, using antidepressant, psychotherapy or a combination of treatment</td>
			</tr>
			<tr id="severe">
				<td>20 or higher</td>
				<td>Severe major depressive disorder.  Warrants treatment with antidepressant, with or without psychotherapy;  follow frequently</td>
			</tr>
		</table>
	</td>
</tr>
</table>
</div>


<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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