<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN">
<!-- saved from url=(0135)file://C:\Documents and Settings\vhapalashfoj\Local Settings\Temporary Internet Files\Content.Outlook\E1VZCGBE\CAPS-sum-2010-12-07.html -->
<HTML><HEAD><TITLE>PTSD Checklist DSM-V Version - MTP21</TITLE>
<META http-equiv=Content-Type content="text/html; charset=iso-8859-1">
<META content=MTP21 name=keywords>
<META content="MTP21 description" name=description>

<SCRIPT language=JavaScript>
<!--
var x = 1;
var num=0;
var datyr = 1900;

var m1=m2=m3=m4=m5=m6=m7=m8=m9=m10=m11=m12=m13=m14=m15=m16=m17=m18=m19=m20=0;
var n1=n2=n3=n4=n5=n6=n7=n8=n9=n10=n11=n12=n13=n14=n15=n16=n17=n18=n19=n20=0;
var r1=r2=r3=r4=r5=r6=r7=r8=r9=r10=r11=r12=r13=r14=r15=r16=r17=r18=r19=r20=" ";

var TEv = new Array(21); // Traumatic event text
var TEs = new Array(21); // Traumatic event score
var TEc = new Array(21); // Cluster item criteria
var TEvs= "";
var TEvt= 0;
var TEt=0;

for (x = 1; x<31; x++) {TEv[x] = "";}
for (x = 1; x<31; x++) {TEs[x] = 0;}
for (x = 1; x<31; x++) {TEc[x] = 0;}

var datafi;

var TEL = new Array(6); // Reporting traumatic event
TEL[0] = " - not at all";
TEL[1] = " - a little bit";
TEL[2] = " - moderately";
TEL[3] = " - quite a bit";
TEL[4] = " - extremely";

var modifier="";

var MFm = new Array(31);
var MIm = new Array(31);
var MFn = new Array(31);
var MIn = new Array(31);
var LFm = new Array(31);
var LIm = new Array(31);
var LFn = new Array(31);
var LIn = new Array(31);
var rMF = new Array(31);

var ifm = new Array(31);
var ifn = new Array(31);

var IIm = new Array(31);
var IIn = new Array(31);

var a1=a2=" ";

var nt=nd=ndM=ntM=ndL=ntL=ne=0;

var ClusB = 0;
var ClusC = 0;
var ClusD = 0;
var ClusE = 0;

ClusBt=" not meeting criteria";
ClusCt=" not meeting criteria";
ClusDt=" not meeting criteria";
ClusEt=" not meeting criteria";

var freqm = new Array(5);

function MTP21_01f(num) {x=num;ne=1;TEs[1]=x;
TEv[1]="1. Having unusual changes in mood"
+TEL[x]+"\r";
prnGI();}

function MTP21_02f(num) {x=num;ne=1;TEs[2]=x;
TEv[2]="2. Feeling down or depressed"
+TEL[x]+"\r";
prnGI();}

function MTP21_03f(num) {x=num;ne=1;TEs[3]=x;
TEv[3]="3. Noticing unexpected or unusual behavior in yourself"
+TEL[x]+"\r";
prnGI();}

function MTP21_04f(num) {x=num;ne=1;TEs[4]=x;
TEv[4]="4. Getting angry with little or no provocation"
+TEL[x]+"\r";
prnGI();}

function MTP21_05f(num) {x=num;ne=1;TEs[5]=x;
TEv[5]="5. Having feelings of anxiety"
+TEL[x]+"\r";
prnGI();}

function MTP21_06f(num) {x=num;ne=1;TEs[6]=x;
TEv[6]="6. Changes in your personality"
+TEL[x]+"\r";
prnGI();}

function MTP21_07f(num) {x=num;ne=1;TEs[7]=x;
TEv[7]="7. Doing things implusively, without thinking them through"
+TEL[x]+"\r";
prnGI();}

function MTP21_08f(num) {x=num;ne=1;TEs[8]=x;
TEv[8]="8. Having difficulty concentrating"
+TEL[x]+"\r";
prnGI();}

function MTP21_09f(num) {x=num;ne=1;TEs[9]=x;
TEv[9]="9. Having difficulty with your memory"
+TEL[x]+"\r";
prnGI();}

function MTP21_10f(num) {x=num;ne=1;TEs[10]=x;
TEv[10]="10. Noticing period of confusion: not knowing the date, where you are"
+TEL[x]+"\r";
prnGI();}

function MTP21_11f(num) {x=num;ne=1;TEs[11]=x;
TEv[11]="11. Being afraid of crowds or being around groups of people"
+TEL[x]+"\r";
prnGI();}

function MTP21_12f(num) {x=num;ne=1;TEs[12]=x;
TEv[12]="12. Being paranoid, thinking people are planning to harm you"
+TEL[x]+"\r";
prnGI();}

function MTP21_13f(num) {x=num;ne=1;TEs[13]=x;
TEv[13]="13. Having difficulty sleeping at night (or during the day)"
+TEL[x]+"\r";
prnGI();}

function MTP21_14f(num) {x=num;ne=1;TEs[14]=x;
TEv[14]="14. Having nightmares that are very vivid, "technicolor""
+TEL[x]+"\r";
prnGI();}

function MTP21_15f(num) {x=num;ne=1;TEs[15]=x;
TEv[15]="15. Difficulty with vision, visual impairment"
+TEL[x]+"\r";
prnGI();}

function MTP21_16f(num) {x=num;ne=1;TEs[16]=x;
TEv[16]="16. Thoughts about doing bad things"
+TEL[x]+"\r";
prnGI();}

function MTP21_17f(num) {x=num;ne=1;TEs[17]=x;
TEv[17]="17. Intrusive thoughts about life and death"
+TEL[x]+"\r";
prnGI();}

function MTP21_18f(num) {x=num;ne=1;TEs[18]=x;
TEv[18]="18. Difficulty with light sensitivityd"
+TEL[x]+"\r";
prnGI();}

function MTP21_19f(num) {x=num;ne=1;TEs[19]=x;
TEv[19]="19. Feelings of being dizzy"
+TEL[x]+"\r";
prnGI();}

function MTP21_20f(num) {x=num;ne=1;TEs[20]=x;
TEv[20]="20. Feeling of being nauseated or vomiting"
+TEL[x]+"\r";
prnGI();}


function dateWri() {
now = new Date;
datyr=0; if(now.getYear()<1900) {datyr=1900;}
document.Form1.datew.value = ((now.getMonth()+1)+"/"+now.getDate()+"/"+(now.getYear()+datyr));
document.Form1.timew.value = (now.getHours()+":"+now.getMinutes());
document.Form2.prnGJ.value = "";
}

function clerit(){
m1=m2=m3=m4=m5=m6=m7=m8=m9=m10=m11=m12=m13=m14=m15=m16=m17=m18=m19=m20=0;
n1=n2=n3=n4=n5=n6=n7=n8=n9=n10=n11=n12=n13=n14=n15=n16=n17=n18=n19=n20=0;
r1=r2=r3=r4=r5=r6=r7=r8=r9=r10=r11=r12=r13=r14=r15=r16=r17=r18=r19=r20="";
for (x = 1; x<31; x++) {TEv[x] = "";}
for (x = 1; x<31; x++) {TEs[x] = 0;}
for (x = 1; x<31; x++) {TEc[x] = 0;}
ClusBt=" not meeting criteria";
ClusCt=" not meeting criteria";
ClusDt=" not meeting criteria";
ClusEt=" not meeting criteria";
dateWri();
}

function prnGI() {
ndM=0;
ntM=0;
ndL=0;
ntL=0;

for (x = 1; x < 21; x++) {
	ndM = ndM + MFm[x] + MIm[x];
	ntM = ntM + MFn[x] + MIn[x];
	ndL = ndL + LFm[x] + LIm[x];
	ntL = ntL + LFn[x] + LIn[x];	
        }

ntM = ntM*4;
ntL = ntL*4;
nt=ntM+ntL+ne;

TEvt=TEv[1]+TEv[2]+TEv[3]+TEv[4]+TEv[5]+TEv[6]+TEv[7]+TEv[8]+TEv[9]+TEv[10]+TEv[11]+TEv[12]+TEv[13]+TEv[14]+TEv[15]+TEv[16]+TEv[17]+TEv[18]+TEv[19]+TEv[20];

TEt=TEs[1]+TEs[2]+TEs[3]+TEs[4]+TEs[5]+TEs[6]+TEs[7]+TEs[8]+TEs[9]+TEs[10]+TEs[11]+TEs[12]+TEs[13]+TEs[14]+TEs[15]+TEs[16]+TEs[17]+TEs[18]+TEs[19]+TEs[20];

for (x = 1; x<31; x++) {TEc[x]=0;}
for (x = 1; x<31; x++) {if(TEs[x]>1) {TEc[x]=1;}}

ClusB = TEc[1]+TEc[2]+TEc[3]+TEc[4]+TEc[5];
ClusBt=" not meeting criteria";if(ClusB>0){ClusBt=" meeting criteria.";}
ClusC = TEc[6]+TEc[7];
ClusCt=" not meeting criteria";if(ClusC>0){ClusCt=" meeting criteria.";}
ClusD = TEc[8]+TEc[9]+TEc[10]+TEc[11]+TEc[12]+TEc[13]+TEc[14];
ClusDt=" not meeting criteria";if(ClusD>1){ClusDt=" meeting criteria.";}
ClusE = TEc[15]+TEc[16]+TEc[17]+TEc[18]+TEc[19]+TEc[20];
ClusEt=" not meeting criteria";if(ClusE>1){ClusEt=" meeting criteria.";}

ClusB = TEs[1]+TEs[2]+TEs[3]+TEs[4]+TEs[5];
ClusC = TEs[6]+TEs[7];
ClusD = TEs[8]+TEs[9]+TEs[10]+TEs[11]+TEs[12]+TEs[13]+TEs[14];
ClusE = TEs[15]+TEs[16]+TEs[17]+TEs[18]+TEs[19]+TEs[20];

TEvs=""; if(TEt==0) {TEvs = " never";}

datyr=0; if(now.getYear()<1900) {datyr=1900;}

modifier = "none or mild";
if(TEt==20) {modifier = "mild to moderate";}
if(TEt>20) {modifier = "moderate";}
if(TEt==40) {modifier = "moderate to severe";}
if(TEt>41) {modifier = "severe";}
if(TEt==60) {modifier = "severe to extreme";}
if(TEt>60) {modifier = "extreme";}

document.Form2.prnGJ.value = 
(((now.getMonth()+1)+"/"+now.getDate()+"/"+(now.getYear()+datyr))+"   "+
(now.getHours()+":"+now.getMinutes())+
"\rMTP21 severity score = "+TEt+
" which suggests " + modifier + " PTSD.\r"+

"\r"+

"The patient"+TEvs+" did experience a traumatic event(s).\r"+

"Cluster B: "+ClusB+ClusBt+"\r"+
"Cluster C: "+ClusC+ClusCt+"\r"+
"Cluster D: "+ClusD+ClusDt+"\r"+
"Cluster E: "+ClusE+ClusEt+"\r"+

"\r"+
TEv[1]+TEv[2]+TEv[3]+TEv[4]+TEv[5]+TEv[6]+TEv[7]+TEv[8]+TEv[9]+TEv[10]+TEv[11]+TEv[12]+TEv[13]+TEv[14]+TEv[15]+TEv[16]+TEv[17]+TEv[18]+TEv[19]+TEv[20]);

}

//-->
</SCRIPT>

<META content="MSHTML 6.00.6000.17092" name=GENERATOR>

</HEAD>


<BODY text=#510000 vLink=#003300 aLink=#ff0000 link=#0000ff bgColor=#b0f0b0 onload=dateWri()><FONT face=Arial>


<TABLE cellSpacing=0 cellPadding=0 width="805" border=0>
  <TBODY>
  <TR>
    <TD>
      <P align=center><BIG><STRONG>MTP - Mefloquine, TBI, PTSD Symptom Scale - 20 items 
      </STRONG></BIG><BR>(to be completed by a subject under supervision of a trained clinician)
	</P></TD></TR></TBODY></TABLE>


<FORM name=Form1 action="/cgi-bin/WRIISC/writetologMTP21.cgi" method=post>

<P>&nbsp;&nbsp;&nbsp; DATE:&nbsp; <INPUT size=8 name=datew>
&nbsp;&nbsp;&nbsp; &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;TIME (24hr):&nbsp; <INPUT size=6 name=timew> 


<INPUT type=hidden value=PCL-civilian-form> 

&nbsp;&nbsp;&nbsp; Patient Code:  &nbsp;<INPUT size-10 name=PCLptcode></P>

<br>INSTRUCTIONS: Below is a list of problems and complaints that people sometimes have in response to toxic exposures, traumatic brain injury, and stressful experiences.  
Please read each one carefully, then click the circle to indicate how much you have been bothered by that problem in the past month, relative to how you were before the exposure.

<br><br>

<TABLE height=20 cellSpacing=1 cellPadding=0 width=810 bgColor=#b0e0b0 
  border=2><TBODY>
  <TR>
    <TD vAlign=top width=502 height=15>
      <P><br><I>&nbsp; In the past month, how much were you bothered by:</I>
      </P></TD>
				
    <TD vAlign=top width=60 bgColor=#e0f0e0 height=15>
      <CENTER>
      <P>Not<br>at all</P></CENTER></TD>

    <TD vAlign=top width=60 height=15>
      <CENTER>
      <P>A little bit</P></CENTER></TD>
    <TD vAlign=top width=60 bgColor=#e0f0e0 height=15>

      <CENTER>
      <P><br>Moderately</P></CENTER></TD>
    <TD vAlign=top width=60 height=15>

      <CENTER>
      <P>Quite<br>a bit</P></CENTER></TD>
    <TD vAlign=top width=60 bgColor=#e0f0e0 height=15>
      <CENTER>

      <P><br>Extremely</P></CENTER></TD></TR>

  <TR>
    <TD vAlign=top width=502 height=20>&nbsp; 1.&nbsp;  Having unusual changes in mood?
 </TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_01f(0)" type=radio value=0 
      name="MTP21_01"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_01f(1)" type=radio value=1
      name="MTP21_01"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_01f(2)" type=radio value=2 
      name="MTP21_01"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_01f(3)" type=radio value=3 
      name="MTP21_01"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_01f(4)" type=radio value=4 
      name="MTP21_01" ><BR><BR></CENTER></TD></TR>

  <TR>
    <TD vAlign=top width=502 height=20>&nbsp; 2.&nbsp; Feeling down or depressed?</TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>

      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_02f(0)" type=radio value=0 
      name="MTP21_02"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_02f(1)" type=radio value=1
      name="MTP21_02"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_02f(2)" type=radio value=2 
      name="MTP21_02"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_02f(3)" type=radio value=3 
      name="MTP21_02"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_02f(4)" type=radio value=4 
      name="MTP21_02" ><BR><BR></CENTER></TD></TR>

  <TR>
    <TD vAlign=top width=502 height=20>&nbsp; 3.&nbsp; Noticing unexpected or unusual behavior in yourself?
</TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_03f(0)" type=radio value=0 
      name="MTP21_03"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_03f(1)" type=radio value=1
      name="MTP21_03"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_03f(2)" type=radio value=2 
      name="MTP21_03"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_03f(3)" type=radio value=3 
      name="MTP21_03"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_03f(4)" type=radio value=4 
      name="MTP21_03" ><BR><BR></CENTER></TD></TR>

  <TR>
    <TD vAlign=top width=502 height=20>&nbsp; 4.&nbsp; Getting angry with little or no provocation</TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_04f(0)" type=radio value=0 
      name="MTP21_04"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_04f(1)" type=radio value=1
      name="MTP21_04"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_04f(2)" type=radio value=2 
      name="MTP21_04"><BR><BR></CENTER></TD>
    <TD vAlign=top width=60 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_04f(3)" type=radio value=3 
      name="MTP21_04"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>

      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_04f(4)" type=radio value=4 
      name="MTP21_04" ><BR><BR></CENTER></TD></TR>


  <TR>
    <TD vAlign=top width=502 height=20>&nbsp; 5.&nbsp; Having feelings of anxiety?</TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>

      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_05f(0)" type=radio value=0 
      name="MTP21_05"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 height=20>

      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_05f(1)" type=radio value=1
      name="MTP21_05"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_05f(2)" type=radio value=2 
      name="MTP21_05"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 height=20>

      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_05f(3)" type=radio value=3 
      name="MTP21_05"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_05f(4)" type=radio value=4
      name="MTP21_05" ><BR><BR></CENTER></TD></TR>


  <TR>
    <TD vAlign=top width=502 height=20>&nbsp; 6.&nbsp; Changes in your personality?</TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_06f(0)" type=radio value=0 
      name="MTP21_06"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_06f(1)" type=radio value=1
      name="MTP21_06"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_06f(2)" type=radio value=2 
      name="MTP21_06"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_06f(3)" type=radio value=3 
      name="MTP21_06"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_06f(4)" type=radio value=4 
      name="MTP21_06" ><BR><BR></CENTER></TD></TR>

  <TR>

    <TD vAlign=top width=502 height=20>&nbsp; 7.&nbsp; Doing things implusively, without thinking them through?</TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_07f(0)" type=radio value=0 
      name="MTP21_07"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_07f(1)" type=radio value=1
      name="MTP21_07"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_07f(2)" type=radio value=2 
      name="MTP21_07"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_07f(3)" type=radio value=3 
      name="MTP21_07"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_07f(4)" type=radio value=4 
      name="MTP21_07" ><BR><BR></CENTER></TD></TR>

  <TR>

    <TD vAlign=top width=502 height=20>&nbsp; 8.&nbsp; Having difficulty concentrating?</TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_08f(0)" type=radio value=0 
      name="MTP21_08"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_08f(1)" type=radio value=1
      name="MTP21_08"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_08f(2)" type=radio value=2 
      name="MTP21_08"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_08f(3)" type=radio value=3 
      name="MTP21_08"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_08f(4)" type=radio value=4 
      name="MTP21_08" ><BR><BR></CENTER></TD></TR>

  <TR>
    <TD vAlign=top width=502 height=20>&nbsp; 9.&nbsp; Having difficulty with your memory?</TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_09f(0)" type=radio value=0 
      name="MTP21_09"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_09f(1)" type=radio value=1
      name="MTP21_09"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_09f(2)" type=radio value=2 
      name="MTP21_09"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_09f(3)" type=radio value=3 
      name="MTP21_09"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_09f(4)" type=radio value=4 
      name="MTP21_09" ><BR><BR></CENTER></TD></TR>

  <TR>
    <TD vAlign=top width=502 height=20>&nbsp;10. Noticing period of confusion; not knowing the date,
<BR>
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; where you are?</TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_10f(0)" type=radio value=0 
      name="MTP21_10"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_10f(1)" type=radio value=1
      name="MTP21_10"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_10f(2)" type=radio value=2 
      name="MTP21_10"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_10f(3)" type=radio value=3 
      name="MTP21_10"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_10f(4)" type=radio value=4 
      name="MTP21_10" ><BR><BR></CENTER></TD></TR>

  <TR>
    <TD vAlign=top width=502 height=20>&nbsp;11. Being afraid of crowds or being around groups of people?</TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_11f(0)" type=radio value=0 
      name="MTP21_11"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_11f(1)" type=radio value=1
      name="MTP21_11"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_11f(2)" type=radio value=2 
      name="MTP21_11"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_11f(3)" type=radio value=3 
      name="MTP21_11"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_11f(4)" type=radio value=4 
      name="MTP21_11" ><BR><BR></CENTER></TD></TR>

  <TR>
    <TD vAlign=top width=502 height=20>&nbsp;12. Being paranoid, thinking people are planning to harm you?</TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_12f(0)" type=radio value=0 
      name="MTP21_12"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_12f(1)" type=radio value=1
      name="MTP21_12"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_12f(2)" type=radio value=2 
      name="MTP21_12"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_12f(3)" type=radio value=3 
      name="MTP21_12"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_12f(4)" type=radio value=4 
      name="MTP21_12" ><BR><BR></CENTER></TD></TR>

  <TR>
    <TD vAlign=top width=502 height=20>&nbsp;13. Having difficulty sleeping at night (or during the day)?</TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_13f(0)" type=radio value=0 
      name="MTP21_13"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_13f(1)" type=radio value=1
      name="MTP21_13"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_13f(2)" type=radio value=2 
      name="MTP21_13"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_13f(3)" type=radio value=3 
      name="MTP21_13"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_13f(4)" type=radio value=4 
      name="MTP21_13" ><BR><BR></CENTER></TD></TR>

  <TR>
    <TD vAlign=top width=502 height=20>&nbsp;14. Having nightmares that are very vivid, "technicolor"?</TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_14f(0)" type=radio value=0 
      name="MTP21_14"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_14f(1)" type=radio value=1
      name="MTP21_14"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_14f(2)" type=radio value=2 
      name="MTP21_14"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_14f(3)" type=radio value=3 
      name="MTP21_14"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_14f(4)" type=radio value=4 
      name="MTP21_14" ><BR><BR></CENTER></TD></TR>

  <TR>

    <TD vAlign=top width=502 height=20>&nbsp;15. Difficulty with vision, visual impairment?</TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_15f(0)" type=radio value=0 
      name="MTP21_15"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_15f(1)" type=radio value=1
      name="MTP21_15"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_15f(2)" type=radio value=2 
      name="MTP21_15"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_15f(3)" type=radio value=3 
      name="MTP21_15"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_15f(4)" type=radio value=4 
      name="MTP21_15" ><BR><BR></CENTER></TD></TR>

  <TR>
    <TD vAlign=top width=502 height=20>&nbsp;16. Thoughts about doing bad things?</TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_16f(0)" type=radio value=0 
      name="MTP21_16"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_16f(1)" type=radio value=1
      name="MTP21_16"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_16f(2)" type=radio value=2 
      name="MTP21_16"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_16f(3)" type=radio value=3 
      name="MTP21_16"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_16f(4)" type=radio value=4 
      name="MTP21_16" ><BR><BR></CENTER></TD></TR>

  <TR>
    <TD vAlign=top width=502 height=20>&nbsp;17. Intrusive thoughts about life and death?</TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_17f(0)" type=radio value=0 
      name="MTP21_17"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_17f(1)" type=radio value=1
      name="MTP21_17"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_17f(2)" type=radio value=2 
      name="MTP21_17"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_17f(3)" type=radio value=3 
      name="MTP21_17"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_17f(4)" type=radio value=4 
      name="MTP21_17" ><BR><BR></CENTER></TD></TR>

  <TR>

    <TD vAlign=top width=502 height=20>&nbsp;18. Difficulty with light sensitivity?</TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_18f(0)" type=radio value=0 
      name="MTP21_18"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_18f(1)" type=radio value=1
      name="MTP21_18"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_18f(2)" type=radio value=2 
      name="MTP21_18"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_18f(3)" type=radio value=3 
      name="MTP21_18"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_18f(4)" type=radio value=4 
      name="MTP21_18" ><BR><BR></CENTER></TD></TR>

  <TR>

    <TD vAlign=top width=502 height=20>&nbsp;19. Feelings of being dizzy? 
	</TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_19f(0)" type=radio value=0 
      name="MTP21_19"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_19f(1)" type=radio value=1
      name="MTP21_19"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_19f(2)" type=radio value=2 
      name="MTP21_19"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_19f(3)" type=radio value=3 
      name="MTP21_19"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_19f(4)" type=radio value=4 
      name="MTP21_19" ><BR><BR></CENTER></TD></TR>

  <TR>

    <TD vAlign=top width=502 height=20>&nbsp;20. Feeling of being nauseated or vomiting? 
</TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_20f(0)" type=radio value=0 
      name="MTP21_20"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_20f(1)" type=radio value=1
      name="MTP21_20"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_20f(2)" type=radio value=2 
      name="MTP21_20"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_20f(3)" type=radio value=3 
      name="MTP21_20"><BR><BR></CENTER></TD>

    <TD vAlign=top width=60 bgColor=#e0f0e0 height=20>
      <CENTER>&nbsp;&nbsp; <INPUT onclick="MTP21_20f(4)" type=radio value=4 
      name="MTP21_20" ><BR><BR></CENTER></TD></TR>
 
</TBODY></TABLE>

<BR><BR>

<p><input type=submit value="SEND DATA TO SERVER FILE">&nbsp;&nbsp;&nbsp;&nbsp;  
<input type=reset onclick="clerit()" value="RESET ALL ANSWERS">

</p>
</form>



<form name="Form2" method="post">
  <p><strong>TEXT FOR YOUR RECORDS</strong></p>

  <p><textarea name="prnGJ" rows="42" cols="72"></textarea> </p>

</form>

  <p>MTP21&nbsp; maximum score = 80 </p>
  <p>
  0&nbsp;&nbsp;&nbsp; -&nbsp;&nbsp;19&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; normal<br>

  20&nbsp;&nbsp;-&nbsp;&nbsp;39&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; mild<br>
  40&nbsp;&nbsp;-&nbsp;&nbsp;59&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; moderate<br>
  60&nbsp;&nbsp;-&nbsp;&nbsp;69&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; severe<br>
  70&nbsp;&nbsp;-&nbsp;&nbsp;80&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; extreme
  </p>

<TABLE cellSpacing=0 cellPadding=0 width=640 border=0>
  <TBODY>
  <TR>

    <TD vAlign=top align=left width=650><FONT face=Arial>
      <CENTER>

 <p>Scale for toxic exposures, TBI, PTSD (5/18/2018)<br>
First draft by Commander William Manofsky
</p>

<P align=center><FONT size=2>Site constructed and maintained by:&nbsp; <A 
                  href="http://www.medafile.com">

		  J. Wesson Ashford, M.D., Ph.D.</A><BR>&nbsp;&nbsp;&nbsp; 
                  <STRONG>Electronic mail address: </STRONG>&nbsp; <A 
                  href="mailto:washford@medafile.com">washford@medafile.com</A><BR>Forms 
                  and papers provided on this site may be copyright protected by 
                  their authors or publishers.<BR>HTML code copyright by J. 
                  Wesson Ashford, M.D., Ph.D., to retain rights for use.<BR>Dr. 
                  Ashford is licensed to practice medicine in the states of California and Kentucky.<BR>

		  &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 
                  Last update:&nbsp; 07/12/2015

</P>

</td>
</TR>
</TBODY></TABLE>
</FONT></BODY></HTML>