One, Five, and Ten Years After the Operation

1Patient ID:______Questionnaire for women who have had a hysterectomyOne, five, and ten years after the operation.How to answer the questionnaire. 2Before answering please read the entire question, including the text as well as the possible answering categories.Most questions should be answered by putting a ring around the number that belongs to the answer you have chosen.Example:1) In general, would you say that your health is:Put one ringExcellent 1 Very good 2 Good 3 Fair 4 Poor 5For other questions rings should be put around numbers in a table.Example: 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?Put a ring in each lineYes NoCut down on the amount of time you spent on work or other activities 1 2Accomplished less than you would like 1 2Were limited in the kind of work or other activities 1 2Had difficulties performing the work or other activities (for example, it took extra 1 2 effort)Please return the filled out questionnaire in the enclosed envolope within ten days. The letter is post free.If you wish to withdraw from the trial and therefore do not wish to answer the questionnaire, please put a ring on the last page of the questionnaire and return the questionnaire anyway. This way you avoid receiving a reminder in three weeks. Thank you for your help.The first part of the questionnaire is about your own perception of your health. 31. In general, would you say that your health is: Put one ringExcellent 1 Very good 2 Good 3 Fair 4 Poor 5 ______2. Compared to one year ago, how would you rate your health in general now?Put one ringMuch better now 1 Somewhat better now 2 About the same 3 Somewhat worse now 4 Much worse now 5 ______3. The following questions are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?4Put one ring in each lineYes, Yes, limited a No, not limited a lot little limited at all Vigorous activities, such as running, lifting heavy objects, 1 2 3 participating in strenuous sports Moderate activities, such as moving a table, pushing a vacuum 1 2 3 cleaner, bowling, or playing golf Lifting or carrying groceries 1 2 3Climbing several flights of stairs 1 2 3 Climbing one flight of stairs 1 2 3 Bending, kneeling or stooping 1 2 3 Walking more than a mile 1 2 3 Walking several blocks 1 2 3 Walking one block 1 2 3 Bathing or dressing yourself 1 2 3______4. During the past 4 weeks, have you had any of the following problems with your work or other regular activities as a result of your physical health?Put one ring in each line 5Yes No Cut down on the amount of time you spent on work or other 1 2 activities Accomplished less than you would like 1 2 Were limited in the kind of work or other activities 1 2 Had difficulties performing the work or other activities (for 1 2 example, it took extra effort)______5. During the past 4 weeks, have you had any of the following problems with your work or other regular activities as a result of any emotional problems (such as feeling depressed or anxious)?Put one ring in each lineYes No Cut down on the amount of time you spent on work or other 1 2 activities Accomplished less than you would like 1 2 Didn't do work or other activities as carefully as usual 1 2______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?Put one ringNot at all 1 Slightly 2 6Moderately 3 Quite a bit 4 Extremely 5 ______7. How much bodily pain have you had during the past 4 weeks?Put one ringNone 1 Very mild 2 Mild 3 Moderate 4 Severe 5 Very severe 6 ______8. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the house and housework)?Put one ringNot at all 1 A little bit 2 Moderately 3 Quite a bit 4 Extremely 5 ______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…… Put one ring in each line 7All of Most A good Some A little None of the of the bit of of the of the the time time time the time time time Did you feel full of pep? 1 2 3 4 5 6 Have you been a very 1 2 3 4 5 6 nervous person? Have you felt so down in the dumps that nothing 1 2 3 4 5 6 could cheer you up? Have you felt calm and peaceful? 1 2 3 4 5 6 Did you have a lot of 1 2 3 4 5 6 energy? Have you felt downhearted 1 2 3 4 5 6 and blue? Did you feel worn out? 1 2 3 4 5 6 Have you been a happy 1 2 3 4 5 6 person? Did you feel tired? 1 2 3 4 5 6 ______10. During the past 4 weeks, how much of the time has your physical health or your emotional problems interfered with your social activities (like visiting friends, relatives, etc.)?Put one ringAll the time 1 Most of the time 2 Some of the time 3 A little of the time 4 None of the time 5 8______11. How TRUE or FALSE is each of the following statements for you?Put one ring in each lineDefinitely Mostly Don't Mostly Definitely true true know false false I seem to get sick a little easier than other people 1 2 3 4 5 I am as healthy as anybody I know 1 2 3 4 5 I expect my health to get worse 1 2 3 4 5 My health is excellent 1 2 3 4 5______The nex questions are about pelvic pain.12. During the past 4 weeks, have you suffered from pelvic pain?Put one ringYes 1 No 2 ______13. During the past 4 weeks, has one or more of the following situations given rise to your pelvic pain? Put one or more rings Menstrual period 1 Intercourse 1 Physical activities 1 Other______1 I don't suffer from pelvic pain 1 ______914. During the past 4 weeks, has one or more of the following situations increased your pelvic pain? Put one or more ringsMenstrual period 1 Intercourse 1 Physical activities 1 Other______1 I don't suffer from pelvic pain 1 ______15. Does pelvic pain interfere with your daily activities?Put one ringYes 1 No 2 I don't know 3 ______16. After the operation, has your pelvic pain changed?Put one ringYes, it has disappeared 1 Yes, it has decreased 2 No, it is unchanged 3 Yes, it has increased 4 ______The questions in the next paragraph are about menopause.17. Do you think that you have passed menopause?Put one ringYes 1 No 2 I don't know 3 ______1018. During the past 12 months, have you been bothered by one or more of the following symptoms?Put one or more ringsDryness of the vagina 1 Hot flushes 1 Nightly flushes 1 Mood swings 1 Experience difficulty focusing 1 None of the above 1 I don't know 1 ______19. Do you take HRT or birth control pills? Also put a ring around "Yes", if you use hormone plaster, hormone gel, hormone crème, or hormone vagitories.Put one ringYes 1 No 2 ______20. Please, write the name of your hormone therapy? Please, also write the name, if it is hormone plaster, hormone gel, hormone creme, hormone vagitories or birth control pills.______Here are some questions about vaginal bleeding.If you have had a total hysterectomy, you are not supposed to answer the questions in the following paragraph. Please go to the questions on urinary function from question number 24 on page 12. ______Some women, who have had a subtotal hysterectomy, still experience vaginal bleeding after the operation. The vaginal bleeding might be regular like menstrual periods or irregular, or they might be like spottings. The vaginal bleeding is considered regular, when the number of days from the first day of one 11 bleeding to the first day of the next only varies 3-4 days. The number of days between two bleedings might exceed one month.21. During the past year, how did you usually experience the timing of your vaginal bleeding?Put one ringIt was regular 1 It was irregular 2 Sometimes regular, sometimes irregular 3 I did not have vaginal bleeding 4 I don't know 5 ______22. During the past year, how did you usually experience the quality of your vaginal bleeding?Put one ringVery heavy 1 Heavy 2 Normal 3 Weak 4 Very weak 5 I did not have vaginal bleeding 6 ______23. During the past year, to what extent has your vaginal bleeding interfered with your work (at home or outside of home)?Put one ringExtremely 1 Quite a bit 2 Moderately 3 Slightly 4 Not at all 5 ______The questions in the next paragraph are about your urinary function. 12Through the questions in the next paragraph we are interested in how things usually are with you.24. During 24 hours, how many times do you usually have to pass water?Put one ring1 - 3 times 1 4 - 10 times 2 More than 10 times 3 ______25. At night, do you have to get out of bed to pass water?Put one ringYes 1 No 2 ______26. At night, how many times do you have to pass water?Put one ring0-2 times per night 1 More than twice per night 2 Not every night 3 Never 4 ______27. Do you experience pain passing the water?Put one ringYes 1 No 2 ______28. Please, describe your passing the water?Put one ring Extreme 1 Quite a bit 2 Moderate 3 13Slight 4 No pain at all 5 ______29. During the past year, how often did you experience urinary tract infection?Put one ringAll the time 1 Often 2 Every now and then 3 Rare 4 Never 5 ______30. Do you have the feeling of incomplete bladder emptying, while passing the water?Put one ringNever 1 Rare 2 Often 3 Always 4 ______31. Do you have to strain to pass water?Put one ring Never 1 Rare 2 Often 3 Always 4 ______32. Please, describe the quality of your stream when passing the water?Put one ringHeavy 1 Normal 2 14Poor 3 ______33. Do you have to do something special to empty your bladder?Put one ring Yes, I sometimes/always use a katheter 1 Yes, I do double/triple voiding 2 No 3 Other______4 ______34. Does urinary incontinence usually interfere with your daily life?Put one ringAlways 1 Often 2 Rare 3 Never 4 ______35. In which situations do you usually experience urinary incontinence?Put one or more ringsAlways 1 During intercourse 1 During urge to pass the urine 1 During cough, sneeze or laughter 1 Sport or other physical activity 1 Never 1 ______36. During the past year, did you experience descensus or prolapse of your bladder?Put one ringYes 1 15No 2 ______37. If you have had a total hysterectomy, did you experience descensus or prolapse/drag of your vagina during the past year?Put one ringYes 1 No 2 a. If you have had a subtotal hysterectomy, did you experience descensus or prolapse/drag of your uterine cervix during the past year?Put one ringYes 1 No 2 ______38. Does your urinary function interfere with your daily life?Put one ringYes, it is a big problem 1 Yes, it is a problem 2 Yes, but it is only a minor problem 3 No, it is no problem 4 ______The next questions are about your bowel function.39. How often do you usually open your bowels? Put one ring 16Twice or more a day 1 Once a day 2 Every 2.- 3. day 3 Once a week or less 4 ______40. Do you need to use laxatives to open your bowels?Put one ringYes 1 No 2 ______41. Please, describe the consistency of your stools?Put one ringThin 1 Normal 2 Hard 3 ______42. Do you usually or often experience incontinence of flatus?Put one ringYes 1 No 2 ______43. Do you usually or often experience incontinence of stool?Put one ringYes 1 No 2 ______44. Do you experience pain when opening your bowels?17Put one ringYes 1 No 2 ______45. Does your bowel function interfere with your daily life?Put one ringYes, it is a big problem 1 Yes, it is a problem 2 Yes, but it is only a minor problem 3 No, it is no problem 4 ______46. During the past year, have you experienced descensus or prolapse of your bowel through your vagina?Put one ringYes 1 No 2 ______Now some questions about your partner.47. Do you have a partner?Put one ringYes 1 No 2 ______48. For how long time have you had your partner?Write the number of months or years.______years______months ______1849. How is the relationship to your partner?Put one ringExcellent 1 Good 2 Fair 3 Poor 4 I don't know 5 I don't have a partner 6 ______The next questions are about your sexual life.For many different reasons women experience varying degree of desire for sex and intercourse. Through the next pages we would like to know how things have been with you during the past year.50. Do you experience pain during intercourse?Put one ringYes 1 No 2 ______51. Where do you feel the pain during intercourse?Put one or more rings 19At the entrance of the vagina 1 Deep in the vagina 1 At the perineum 1 Other______1 I don't experience pain during intercourse 1 ______52. How often do you desire sex?Put one ringAlmost never 1 Less than once a month 2 2-4 times a month 3 1-2 times a week 4 More than twice a week 5 ______53. How often do you have intercourse?Put one ringAlmost never 1 Less than once a month 2 2-4 times a month 3 1-2 times a week 4 More than twice a week 5 ______Women achieve sexual satisfaction (orgasm) in many different ways. Some achieve sexual satisfaction (orgasm) through self-satisfaction (masturbation), some through intercourse and others through both acts.______54. How often do you satisfy yourself (masturbate)?Put one ring 20Never 1 Less than once a year 2 Less than once a month 3 2-4 times a month 4 1-2 times a week 5 More than twice a week 6 ______55. Do you achieve sexual satisfaction (orgasm) during intercourse?Put one ringNever 1 Rare 2 Often 3 Always 4 a) If you achieve satisfaction (orgasm), how does it happen?Put one or more ringsBy stimulating the clitoris 1 By deep penetration of the penis 1 Other______1 ______56. Please describe the quality of your satisfaction (orgasm)?Put one ringExcellent 1 Good 2 Fair 3 I don't achieve satisfaction 4 ______57. Are you satisfied with your sexual life?Put one ring 21Yes 1 No 2 I don't know 3 ______Finally, some questions about your health and your work.58. How much do you weigh?______kg ______59. Have you paid a visit to your doctor's during the past year?Put one ringYes 1 No 2 I don't know 3 ______60. What was the reason for visiting your doctor? Please write.______61. During the past year, have you been admitted to the hospital?Put one ringYes 1 No 2 22______62. What was the reason for your hospital stay? Please write.______63. Do you take any kind of medicine daily or weekly?Put one ringYes 1 No 2 ______64. What kind of medicine do you take? Please write. Also write the name if the medicine is HRT.______65. Has your work changed during the past year?Put one ringYes, I am working outside of home 1 Yes, I am working at home 2 Yes, I am on leave 3 Yes, I am unemployed 4 Yes, I have retired 5 No 6 Other______7 ______66. Do you know something about the operation now that you would have liked to know before the operation? Please write. 23______Thank you for answering the questionnaire.If you wish to make comments about questions or about the entire trial, please write them here: 24I want to withdraw from the trial 1Reasons for withdrawal:I want to withdraw on a question of principle 1 I want to withdraw because of disease 2 Other (please write):______3Drawing on the front page by Ingeborg Gimbel.

One, Five, and Ten Years After the Operation

Details

Download

Copyright

We respect the copyrights and intellectual property rights of all users. All uploaded documents are either original works of the uploader or authorized works of the rightful owners.

Support