SRA-34. Subjects Response to Antipsychotics. Short version (English) Brief questionnaire to evaluate desired and undesired effects of antipsychotics
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1 SRA-34 Subjects Response to Antipsychotics Short version (English) Brief questionnaire to evaluate desired and undesired effects of antipsychotics I.M. Lako H.A. Wolters H. Knegtering D. Wiersma R. Bruggeman Universitary Medical Center Groningen (UMCG) Groningen, The Netherlands SRA-34 - Subjects Response to Antipsychotics Psychiatry UMCG/Rob Giel nderzoekcenter (RGc), rgoc@.umcg.nl
2 Background information Date:... What is your sex? 1. Male 2. Female What is your age?... Years What is your current civil status? 1. Married 2. Living together 3. Single 4. Divorced 5. Widow / widower 6. ther relationship Which education did you complete? 1. None 2. Primary school 3. Secondary school 4. Technical college 5. Higher National Diploma 6. University 7. ther If you know which illness(es) you, according to the doctor, suffer from, state this below If you know the names and dosage of the medicine you take, please state this below. dose During which period of time have you been taking your current antipsychotic medicine? 1. Less than 1 month 2. Between 1 and 3 months 3. Between 3 and 12 months 4. Between 1 and 2 years 5. More than 2 years How do you take the antipsychotic medicine? 1. ral (pills) 2. Depot (injection) Do you take the medication as prescribed? 1. I mostly take the medication as prescribed 2. I miss taking the antipsychotic medicine a few times a month 3. I miss taking the antipsychotic medicine a few times a week 4. I never take the antipsychotic medicine 3... Psychiatry UMCG/Rob Giel nderzoekcenter (RGc), rgoc@umcg.nl
3 Introduction This questionnaire consists of experiences one could have when one takes antipsychotic medicine. The question is whether you have had this experience during the past week due to the antipsychotic medication. At the end of the questionnaire there are three concluding questions. There are no correct or incorrect answers, it s your own opinion that counts. Example: 1. I can think more clearly If, during the past week, you have had the idea to a high degree that you think more clearly due to the antipsychotic medication, then the answer is: yes, to a high degree. If, during the past week, you have had the idea that to a certain degree you think more clearly due to the antipsychotic medication, then the answer is: yes, to a certain degree. If, during the past week, you haven t had the idea that you think more clearly due to the antipsychotic medication, then the answer is: no. Attention! If, during the past week, you have had the idea that you think more clearly, but that it s not due to the antipsychotic medication, then the answer is also no. Psychiatry UMCG/Rob Giel nderzoekcenter (RGc), rgoc@umcg.nl
4 certain degree high degree No 1 My emotions are dull EF 2 I feel happier RA 3 My weight has increased WA 4 I have less energy for socializing SW 5 I can t remember well SD 6 I react more slowly SD 7 I am less anxious RP 8 I feel more depressed DS 9 I am constipated more often U 10 I can concentrate better RA 11 I leak urine more often U 12 My vision is more blurred U 13 I have more trouble sitting still U 14 I hear fewer voices RP 15 It is more difficult for me to have an orgasm SP 16 I have a dry mouth more often U 17 My memory has improved RA 18 I have more tremors EP 19 I have more interest in my surroundings RS 20 I am nauseous more often U 21 My sex drive has decreased SP 22 I am dizzy more often U 23 Dealing with others is easier RS 24 I can think more clearly RC 25 I get physically tired more easily SW 26 I have more difficulty waking up IS 27 I am less creative U 28 My muscles are more stiff EP 29 I have more control over my thoughts RC 30 I have increased salivation U Psychiatry UMCG/Rob Giel nderzoekcenter (RGc), rgoc@umcg.nl
5 certain degree high degree No 31 I have more trouble concentrating SD 32 I have an increased appetite WA 33 I can sleep better RIS For females only: 34 I menstruate less often U Concluding questions: C1 I am satisfied with the antipsychotic medication C C2 I feel dependent on antipsychotic medication in order to function C C3 The advantages of antipsychotic medication outweigh the disadvantages C Thank you for your response. Below you can state any other experiences with antipsychotic medication, desired or undesired: Legend. SRA-34 subscales (item number) Undesired effects Desired effects WA Weight & Appetite (3,32) IS Increased Sleep (26) RP Recovery Psychosis (7,14) SP Sexual Problems (15,21) SW Social Withdrawal (4,25) RC Recovery Cognition (24,29) SD Slowed Down (5,6,31) EF Emotional Flattening (1) RS Recovery Social (19,23) EP EPS (18,28) DS Depressive Symptoms (8) RA Recovery Attention (2,10,17) U ther Undesired effects (9,11,12,13,16,20,22,27,30,34) RI Recovery Increased Sleep (33) Psychiatry UMCG/Rob Giel nderzoekcenter (RGc), rgoc@umcg.nl
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PATIENT HISTORY FORM
BodyCheck Prevention & Health Physical Therapy Centre PATIENT HISTORY FORM Please assist us by answering the following questions as completely and accurately as possible. Your answers will assist us by
SCOPA-AUT. 1. In the past month, have you had difficulty swallowing or have you choked?
SCOPA-AUT By means of this questionnaire, we would like to find out to what extent in the past month you have had problems with various bodily functions, such as difficulty passing urine, or excessive