Consent Form (Bangla)
গবেষণাধীন েযাক্তির গবেষণাকবম ে অংশগ্রহবণর সম্মতিপত্র
আমি মিম্নস্বাক্ষরকারী /টিপসই দািকারী এই ির্ি ে জাির্ে পারলাি যে, বঙ্গবন্ধু যেখ
িুজজব যিমির্কল মবশ্বমবদযালর্ের এিমিল যকার্সরে গর্বষক িাাঃ োহিীিা িাজিীি
এযামি “Neuropsychiatric Adverse Effects in Patients Treated with Montelukast at
Rajshahi Medical College Hospital” এর উপর গর্বষণা কাজ পমরচালিা করর্েি।
মেমি আিার্ক গর্বষণা কাজটির উর্েেয, পদ্ধমে ও সিেকাল, গর্বষণাে
অংেগ্রহর্ণর ির্ল আিার সুমবধা, অসুমবধা, আিার েথ্য সিূর্হর প্রর্োজিীে
যগাপিীেো রক্ষার মবষে সম্পর্কে মবস্তামরে ভার্ব অবমহে কর্রর্েি। মেমি আিার্ক
আশ্বস্থ কর্রর্েি যে, এই গর্বষণাে অংে গ্রহণ সম্পূণ ে আিার ইচ্ছাধীি, অংেগ্রহর্ণর
যস যকাি পোর্ে
ে আপমি জািার্ল আর্ির্ক গর্বষণা যথ্র্ক অবযহমে যদো হর্ব এবং
এর্ে আিার যকাি অসুমবধা বা ক্ষমে হর্ব িা। আমি আরও যজর্িমে যে, আিার
মিকি যথ্র্ক সংগৃমহে উপাি সিূহ োাঁর এিমিল গর্বষণার কার্জ বযবহামরে হর্ব।
উর্েমখে মবষোমদ যজর্ি আমি সজ্ঞার্ি ও যস্বচ্ছাে এই গর্বষণাে অংেগ্রহর্ণর সম্মমে
প্রদাি কমরলাি।
অংেগ্রহণকারীর স্বাক্ষর / টিপসই
িািাঃ
প্রের্নাঃ
টিকািাাঃ
Data Collection Form
(Department of Pharmacology and Therapeutics, Rajshahi Medical College, Rajshahi)
Study Title: Neuropsychiatric Adverse Effects in Patients Treated with
Montelukast at Rajshahi Medical College Hospital.
Sl. No………………………………………… Date…………………………………..
Name of respondents………….……………….Address …………………………….....
Variables:
1. Age ……………………….years /_____/
2. Sex 1=Male 2=Female /_____/
3. Religion 1=Muslim 2=Hindu /_____/
3=Christian 4=Buddhist
5=Others………………………………………. (Please mention)
4. Residential 1=Rural 2=Urban /_____/
status
3=Semi-urban
5. Educational
1=Illiterate/Read & write 2=Primary /_____/
status
3=Secondary 4= Higher secondary
5=Honors/Masters 6=Graduate plus
7=Others……………………………………….. (Please mention)
6. Occupational 1=Housewife 2=Day labour /_____/
status
3=Farmer 4=Govt. service
5=NGO worker 6= Businessman
7=Others……………………………………….. (Please mention)
7. Monthly Family Income……………….…………………taka /_____/
8. Height ………………………... meter /_____/
9. Weight …………………………Kg /_____/
10. Pulse …………………………beat/min /_____/
11. Blood pressure …………………………mmHg /_____/
Mood Disorder Questionnaire (MDQ)
Instructions: Check ( 3) the answer that best applies to you.
Has there ever been a period of time when you were not your usual self and… Yes No
1. …you felt so good or so hyper that other people thought you were not your normal
1 0
self or you were so hyper that you got into trouble?
2. …you were so irritable that you shouted at people or started fights or arguments? 1 0
3. …you felt much more self-confident than usual? 1 0
4. …you got much less sleep than usual and found you didn’t really miss it? 1 0
5. …you were much more talkative or spoke faster than usual? 1 0
6. ...thoughts raced through your head or you couldn’t slow your mind down? 1 0
7. ...you were so easily distracted by things around you that you had trouble
1 0
concentrating or staying on track?
8. ...you had much more energy than usual? 1 0
9. ...you were much more active or did many more things than usual? 1 0
10. ...you were much more social or outgoing than usual, for example, you telephoned
1 0
friends in the middle of the night?
11. ...you were much more interested in sex than usual? 1 0
12. ...you did things that were unusual for you or that other people might have thought
1 0
were excessive, foolish, or risky?
13. ...spending money got you or your family into trouble? 1 0
14. If you checked YES to more than one of the above, have several of these ever
1 0
happened during the same period of time?
No Minor Moderate Serious
problem problem problem problem
15. How much of a problem did any of these
cause you — like being unable to work;
0 1 2 3
having family, money, or legal troubles;
getting into arguments or fights?
Interpretation:
Traditionally, a positive screen on the MDQ requires endorsement of (a) 7 or more of 13
symptom items, (b) multiple symptoms occurring at the same time, and (c) symptoms
causing notable psychosocial impairment (Hirschfeld et al., 2000).
The Neuropsychiatric Inventory Questionnaire
Does the patient have false beliefs, such as thinking that others are stealing
Delusions
from him/her or planning to harm him/her in some way?
Yes No SEVERITY: 1 2 3 DISTRESS: 0 1 2 3 4 5
Does the patient have hallucinations such as false visions or voices? Does
Hallucinations
he or she seem to hear or see things that are not present?
Yes No SEVERITY: 1 2 3 DISTRESS: 0 1 2 3 4 5
Agitation/Aggression Is the patient resistive to help from others at times, or hard to handle?
Yes No SEVERITY: 1 2 3 DISTRESS: 0 1 2 3 4 5
Depression/Dysphoria Does the patient seem sad or say that he /she is depressed?
Yes No SEVERITY: 1 2 3 DISTRESS: 0 1 2 3 4 5
Does the patient become upset when separated from you? Does he/she have
Anxiety any other signs of nervousness such as shortness of breath, sighing, being
unable to relax, or feeling excessively tense?
Yes No SEVERITY: 1 2 3 DISTRESS: 0 1 2 3 4 5
Elation/Euphoria Does the patient appear to feel too good or act excessively happy?
Yes No SEVERITY: 1 2 3 DISTRESS: 0 1 2 3 4 5
Does the patient seem less interested in his/her usual activities or in the
Apathy/Indifference
activities and plans of others?
Yes No SEVERITY: 1 2 3 DISTRESS: 0 1 2 3 4 5
Does the patient seem to act impulsively, for example, talking to strangers
Disinhibition
as if he/she knows them, or saying things that may hurt people's feelings?
Yes No SEVERITY: 1 2 3 DISTRESS: 0 1 2 3 4 5
Is the patient impatient and cranky? Does he/she have difficulty coping
Irritability/Lability
with delays or waiting for planned activities?
Yes No SEVERITY: 1 2 3 DISTRESS: 0 1 2 3 4 5
Does the patient engage in repetitive activities such as pacing around the
Motor Disturbance
house, handling buttons, wrapping string, or doing other things repeatedly?
Yes No SEVERITY: 1 2 3 DISTRESS: 0 1 2 3 4 5
Does the patient awaken you during the night, rise too early in the morning,
Nighttime Behaviors
or take excessive naps during the day?
Yes No SEVERITY: 1 2 3 DISTRESS: 0 1 2 3 4 5
Has the patient lost or gained weight, or had a change in the type of food
Appetite/Eating
he/she likes?
Yes No SEVERITY: 1 2 3 DISTRESS: 0 1 2 3 4 5
________________________
(Signature of the Investigator)
