KSARC Questionnaire. Exceptional healthcare, personally delivered

Transcription

1 KSARC Questionnaire Exceptional healthcare, personally delivered

2 What is the KSARC questionnaire and why have I been given it? The KSARC questionnaire is based on a survey called the King s Sarcoidosis Questionnaire (KSARC) and is useful way to assess the impact sarcoidosis is having on a person s life. Rechecking the KSARC score over the course of the condition, or when a new treatment is tried can provide useful information on how symptoms are affecting you. Occasionally your doctor may ask you to complete the KSARC questionnaire so they can assess the impact the condition is having. This will provide a useful starting point to compare changes in the condition particularly after treatments have been started. Your doctor should advise when to complete the questionnaire and this will normally be before attending a consultation. You may also be given additional booklets with advice on how frequently you should complete them (typically every few weeks or every few months). How do I complete the KSARC questionnaire? You should complete your name and DoB in the box below and the date that you completed the survey. If you know your NHS number you can add this but don t worry if you don t know this. The questionnaire is split into 5 sections; general health status, lungs, medication, skin and eyes. You should read each question and indicate, by ticking the box, the statement which most applies to you. You should answer ALL question as, as honestly as you can and should only tick one box for each question. 3

3 This booklet belongs to: Date of Birth: / / NHS Number: Date of survey: / / 4

4 General Health Status 1. In the last 2 weeks I have felt frustrated A little of the time 2. In the last 2 weeks I have had trouble concentrating A little bit of the time 3. In the last 2 weeks I have lacked motivation A little bit of the time 4. In the last 2 weeks I have felt tired A little bit of the time 5

5 5. In the last 2 weeks I have felt anxious A little of the time 6. In the last 2 weeks I have felt aches and pains in my muscles / joints A little bit of the time 7. In the last 2 weeks I have felt embarrassed A little bit of the time 8. In the last 2 weeks I have worried about my weight A little bit of the time 6

6 9. In the last 2 weeks I have worried about my sarcoidosis A little of the time 10. In the last 2 weeks tiredness has interfered with my normal social activities such as going out with friends / family A moderate amount A modest amount 7

7 Lungs 11. In the last 2 weeks my cough has caused pain or discomfort A little of the time 12. In the last 2 weeks I have been breathless, climbing stairs or walking up straight inclines A little bit of the time 13. In the last 2 weeks I have had to take deep breaths, also known as air hunger A little bit of the time 14. In the last 2 weeks my chest felt tight A little bit of the time 8

8 15. In the last 2 weeks I have had episodes of breathlessness A little of the time 16. In the last 2 weeks I have experienced chest pains A little of the time 9

9 Medication 17. I the last 2 weeks I have worried about the side effects of my medication for sarcoidosis A moderate amount A modest amount 18. I the last 2 weeks I have felt worse because of my medication for sarcoidosis A moderate amount A modest amount 19. I the last 2 weeks I have gained weight because of my medication for sarcoidosis A moderate amount A modest amount 10

10 Skin 20. I the last 2 weeks I have been bothered by my skin problems A moderate amount A modest amount 21. I the last 2 weeks I have been concerned about changes in colour of my skin lesions A moderate amount A modest amount 22. I the last 2 weeks I have been embarrassed about my skin A little of the time 11

11 Eyes 23. I the last 2 weeks I have had dry eyes A little of the time 24. I the last 2 weeks I have had difficulty with bright lights A little of the time 25. I the last 2 weeks my eyes have been red A little of the time 26. I the last 2 weeks I have had pain in/or around the eyes A little of the time 12

12 27. I the last 2 weeks I have had difficulty reading A little of the time 28. I the last 2 weeks I have had blurred vision A moderate amount A modest amount 29. I the last 2 weeks I have been worried about my eyesight A moderate amount A modest amount 13

13 Any other notes or comments: 14

14 Assessor to complete Domains (questions): (a) General health status (b) Lung (c) Medication (d) Skin (e) Eyes (./203) (./70) (./42) (./21) (./21) (./49) NHS Constitution. Information on your rights and responsibilities. Available at 15

15 How to contact us: If you or the individual you are caring for need support reading this leaflet please ask a member of staff for advice. North Bristol NHS Trust. This edition published May Review due May NBT002786