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Thank you for taking part in the Canterbury Ileal Pouch study. This is one of the questionnaires that we would like you to complete; it is about the impact your ileal pouch has had on your quality of life, and it should take approximately 15 minutes of your time.
Your participation in this study is completely voluntary. There are no foreseeable risks associated with this project. However, if you feel uncomfortable answering any questions, you can choose the option of "decline to answer". PLEASE NOTE that there is no save and continue option, so PLEASE DO NOT SHUT DOWN THE QUESTIONNAIRE BEFORE ITS COMPLETION. Thank you very much for your time. It is very important for us to learn your opinions.
Your questionnaire responses will be strictly confidential. If you have questions at any time about the questionnaires or the study, please feel free to contact me by email at: [email protected]
Please start the questionnaire now by clicking on the Continue button below. |
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| Instructions for this questionnaire: Please answer every question. Some questions may look like others, but each one is different. Please take the time to read and answer each question carefully by selecting the answer that best represents your response. |
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| * What is your Study ID? (This was given to you in an email or a letter; if you have lost your study ID please email Alex at [email protected]) | | |
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| * 1. In general, would you say your health is? |
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| * 2. Compared to one year ago, how would you rate your health in general now? |
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* 3. The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?
a. Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports. |
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| * b. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf. |
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| * c. Lifting or carrying groceries. |
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| * d. Climbing several flights of stairs. |
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| * e. Climbing one flight of stairs. |
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| * f. Bending, kneeling or stooping. |
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| * g. Walking more than one mile. |
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| * h. Walking several blocks. |
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| * j. Bathing or dressing yourself. |
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* 4. During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health?
a. Cut down the amount of time you spent on work or other activities? |
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| * b. Accomplished less than you would like? |
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| * c. Were limited in the kind of work or other activities |
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| * d. Had difficulty performing the work or other activities (for example, it took extra time) |
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* 5. During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)?
a. Cut down the amount of time you spent on work or other activities? |
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| * b. Accomplished less than you would like? |
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| * c. Didn't do work or other activities as carefully as usual? |
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| * 6. During the past 4 weeks, to what extent has your physical health or emotional problems interfered with your normal social activities with family, friends, neighbors, or groups? |
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| * 7. How much bodily pain have you had during the past 4 weeks? |
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| * 8. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)? |
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* 9. These questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling.
How much of the time during the past 4 weeks:
a. did you feel full of pep? |
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| * b. have you been a very nervous person? |
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| * c. have you felt so down in the dumps nothing could cheer you up? |
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| * d. have you felt calm and peaceful? |
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| * e. did you have a lot of energy? |
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| * f. have you felt downhearted and blue? |
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| * g. did you feel worn out? |
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| * h. have you been a happy person? |
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| * 10. During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting friends, relatives, etc.)? |
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* 11. How TRUE or FALSE is each of the following statements for you?
a. I seem to get sick a little easier than other people |
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| * b. I am as healthy as anybody I know |
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| * c. I expect my health to get worse |
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| * d. My health is excellent |
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| This is an optional part of the study, where you can choose to share with us any thoughts or comments you have from your experience of living with an ileal pouch. We also welcome any feedback about the study. | | |
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