1. Date questionnaire is filled in: (year, month, day)

Transcription

1 Gynecological and general health declaration prior to possible surgery. Name Mrs Hysterectomy 44 years Social Security No Patient s address Social Security No.: Name... Address... Postal code...city... Ph. home... Ph. work... Cell/other telephone If information is missing or incorrect please fill this out You will notice there are some gaps in your questionnaire. This is where certain questions have been left out as they do not apply to you. You can preferably complete the questionnaire on website go to log in your password is rtud88 1. Date questionnaire is filled in: (year, month, day) 2. A surgery may include different stages and involve more than one organ. Which of the following procedures will be included in your operation? Removal of uterus (hysterectomy) Intrauterine surgery (e.g. heat treatment, or TCRE) Removal of one ovary Removal of both ovaries Surgery on cysts Surgery on fallopian tube(s) Prolapse surgery Surgery on fallopian tube(s) Surgery for muscular tumors (myomas) Other surgery on ovaries/fallopian tubes Other surgery Specify if possible? I don t know which surgery is being planned 1

2 3. Rank the reasons for your seeking medical help below. Write 1 for the most important reason for your seeking health care; 2 for the second most important reason, and so on. Please try to avoid using the same number twice. Leave unmarked any reasons that don t apply to you. Write the numbers inside the boxes, e.g Pain Hemorrhage Pressure or inconvenience associated with extra weight (e.g. a heavy feeling, pressure on bladder or bowel) Prolapse (tissue sticking out of the vagina) Urine leakage/urinary incontinence Other ailments/reasons. If so, which? b. For how long have you experienced the No. 1 cause, i.e. the most important reason for your seeking medical help? Number of years,.. months, or days Do you have pain in the genital area? No Yes. Rate the degree of pain by writing an X on the line. Period pain, regular monthly pain No pain unbearable The pain lasts for days Abdominal pain No pain unbearable Other pain in the genitalia, describe... No pain unbearable... 5a. Have you menstruated/experienced genital bleeding in the past year? Yes No i. Are your periods regular? Yes No ii. Do you experience unexpected, irregular bleeding? iii. Do you use hormone treatment that causes regular bleeding? Yes No Yes No 5b. If you experience menstruation/genital bleedings, how heavy are they? Have none/have stopped Small Moderate Heavy Very heavy Varies a lot from one time to another 2

3 5c. Which/what medication(s) have you received to help with bleeding over the past three years? No medication Iron supplements Birth control pills Gestagens (Corpus luteum hormone, e.g. Depo-Provera, Gestapuran, Provera, Primolut-Nor or Orgametril) Cyklokapron, Cyklo-F, Tranon Other, what... 5e. Have you used or do you currently use a hormone IUD (Levonova/Mirena)? No Don t know Yes. When, approximately, was it inserted? State: year... month... If it has been removed, when approximately? State: year... month... 6a. Does it ever feel as though something is sticking out of your vagina? Never Almost never 1 3 times per month 1 3 times per week Every day 6b. Do you ever experience a feeling of chafing in your genital area? Never Almost never 1 3 times per month 1 3 times per week Every day 6c. If you strain yourself, e.g. by lifting heavy things, do the problems you have become Better Stay the same Worse I have no problems 7a Do you have difficulties emptying your bladder? Never Almost never 1 3 times per month 1 3 times per week Every day 7b Do you have any problems with urinary urgency (a sudden, strong urge to pee)? Never Almost never 1 3 times per month 1 3 times per week Every day 7c Do you need to get up during the night to pee? Never Almost never 0 1 time Most often once a night Most often twice a night More than twice a night 7d Do you experience incontinence or the involuntary release of urine? Never Almost never 1 3 times per month 1 3 times per week Every day If you answered Never or Almost never to question 7d above, skip to question 9 3

4 Mark one of the alternatives given for each of the questions from 8b 8k. 8b How often do you experience incontinence during physical activity, when you laugh, cough or sneeze? Never 1 4 times a month 1 6 times a week Once a day More than once a day 8d. How often do you experience a sudden, strong feeling that you need to pee, after which you leak urine before you are able to reach a toilet? Never 1 4 times a month 1 6 times a week Once a day More than once a day 8f. If suffer from incontinence both during physical activity (e.g. coughing, heavy lifting, exercise) and when experiencing urinary urgency (a sudden, strong urge to pee), when do experience the most trouble? incontinence during physical activity is worse than incontinence during urinary urgency incontinence during urinary urgency is worse than incontinence during physical activity the same degree of incontinence during urinary urgency as during physical activity no incontinence during physical exertion or urinary urgency 9a Do you have trouble emptying your bowels? Never Hardly ever 1 3 times a month 1 3 times a week Every day 9b Do you ever need to press on the rear wall of your vagina to be able to empty your bowels? Never Hardly ever 1 3 times a month 1 3 times a week Every day 9c Do you ever experience leakage of solid feces? Never Hardly ever 1 3 times a month 1 3 times a week Every day 10a. Have you had intercourse in the last 3 months? Yes No If Yes, How intense is the pain during intercourse? No pain Unbearable pain Have you used any contraceptive device in the last three months? Yes No Which contraceptive?... 4

5 IN ORDER TO ASSESS YOUR SITUATION AND PLAN YOUR GYNECOLOGICAL TREATMENT AS WELL AS POSSIBLE, WE WOULD LIKE TO ASK YOU FOR SOME BACKGROUND INFORMATION. 11. What is currently your primary occupation? Are you employed? Yes No Employed, profession:... Full-time Part-time Physically demanding job Non-physically demanding job Other Are you currently on paid sick leave? Yes, due to the coming operation Yes, for another reason No, not presently 13a. Number of pregnancies... b. Number of deliveries... c. Number of caesarian sections...d. Number of miscarriages... e. Number of extrauterine pregnancies 14. Are you pregnant now? No Don t know Yes 15. When did your last menstruation period begin? (day, month, year) )a. How long does your period last? The number of days varies between... and... days. b. How many days have passed between the first day of one period, and the first day of your next period: over the last six months? The number of days has varied between... and... days. c. Was it difficult for you to answer the above questions either because your periods are irregular, or because you haven t had one for a long time? Yes No 16. Have you had menopausal symptoms (e.g. hot flashes, sweating or racing pulse) since the surgery? No Yes. State approximately when these symptoms began (year-month) Don t know 5

6 17a. Are you currently taking any hormone treatment containing estrogen? No Yes, to alleviate menopausal symptoms Yes, for problems in the genital region Yes, for problems with urine/urinal tract Yes, for osteoporosis Yes, for another reason (state):... Treatment began (year-month), as well as you are able to remember State the name and dosage of the hormone treatment you use: 18. Has a physician told you that you have or have had any of these diseases/ailments? Mark the ailments a physician has informed you that you have or have had: Mark No if you have not experienced the ailment. Do you still have this ailment? What/which year(s) did you suffer from this ailment? Ovarian inflammation No Yes No Yes Year... Endometriosis No Yes No Yes Year... Ovarian cysts No Yes No Yes Year... Urinary tract infection No Yes No Yes Year... Cell changes in the vaginal portion of No Yes No Yes Year... the cervix Polyps in uterus or vaginal portion of No Yes No Yes Year... the cervix Myomas (muscular tumors) No Yes No Yes Year... Other... No Yes No Yes Year... No, I have none of the above diseases/ailments. 6

7 19. Have you undergone any of the following abdominal/gynecological operations? Which? Mark No for those operations you have not had What year (approx.)? As a laparoscopic procedure Scrapping for bleedings, miscarriage or No Yes Year... abortion? Dilatation and curettage. Changes in the vaginal portion of the cervix? No Yes Year... Cesarean section? No Yes Year... Sterilization? No Yes Year... No Yes Extrauterine pregnancies? No Yes Year... No Yes Cysts, abnormalities in ovaries/fallopian No Yes Year... No Yes tubes? Myomas, muscular tumors? No Yes Year... No Yes Urinary incontinence? No Yes Year... No Yes Prolapse? No Yes Year... No Yes Other gynecological/abdominal surgery? No Yes Year... No Yes... Appendix operation? No Yes Year... No Yes Other abdominal surgery?... No Yes Year... No Yes No, I have not undergone any gynecological/abdominal surgery Have you undergone any other surgical operations (not gynecological/abdominal)? No Yes. Name the operation and what year it took place year IN ORDER TO ASSESS YOUR GENERAL STATE OF HEALTH, WE WOULD LIKE TO ASK YOU TO ANSWER THE FOLLOWING QUESTIONS 20a. How tall are you?... ft....in. b. How much do you weigh?... pounds 21. Do you smoke? Yes, number of cigarettes per day... No, stopped in year... No, I have never smoked 22. Do you usually suffer from motion sickness/sea sickness? No Yes 7

8 23a. Do you have any allergies (hyper-sensitivity)? No Don t know Yes If yes, describe what you react to and the kind of reaction: Are you allergic (hyper-sensitive) to any medication? No Yes If yes, what/which?... 23b.Have you previously had any serious/dangerous allergic reaction (hypersensitivity) which resulted in an emergency hospital visit? No Yes If yes, describe what you reacted to and how: Do you or any of your relatives have a hereditary disease (e.g. porphyria, hereditary muscular diseases or malign hyperthermia)? (Have there been any cases in your family? Have you heard of these diseases?) No Don t know Yes 25. Do you have any of the following problems? Frequent nosebleeds No Yes Bleeding for more than 10 min. from small sores No Yes Large bruises No Yes 26. Has a physician ever informed you that you had an embolism? No Yes If yes, where was the embolism located? 27. a. Do you need to stop and rest after you have walked up two flights of stairs? No Yes b. Do you need to stop and rest after you have walked up half a flight of stairs? No Yes 28. Has a physician ever informed you that you have or have ever had any of the following heart diseases? No Yes If yes, has a physician ever informed you that you have or have had any of the following heart problems? Mark No if you have never had the ailment. Current treatment/ medication? Heart failure No Yes No Yes Year... Heart infarction No Yes No Yes Year... Vascular spasm from the heart No Yes No Yes Year... Heart muscle inflammation No Yes No Yes Year... Cardiac valve dysfunction No Yes No Yes Year... Other heart disease No Yes No Yes Year... No, I have none of the above ailments. If yes, what year did treatment/medication start? 8

9 29. Do you have any lung or airway-related ailments? No Yes If yes, which of the following? Continuous coughing for the last 6 months No Yes There is sometimes a squeaking/hissing noise No Yes when I breathe Asthma No Yes Other ailment No Yes 30. Do you suffer from stomach or bowel problems? No Yes If yes, which ailments? Diarrhea No Yes Vomiting/heartburn No Yes Severe pain No Yes Constipation No Yes Other ailments No Yes 31. Has a physician ever diagnosed any of illnesses listed below? Mark No if you have not had the ailment. Current treatment/ medication? Cerebral hemorrhage? No Yes No Yes Year... High blood pressure? No Yes No Yes Year... Stroke/seizure? No Yes No Yes Year... Kidney problems? No Yes No Yes Year... Goiter? No Yes No Yes Year... Diabetes? No Yes No Yes Year... Liver/gall disease? No Yes No Yes Year... Hepatitis? No Yes No Yes Year... No, I have none of the above ailments. If yes, what year did treatment/medication start? Has a physician ever diagnosed any of illnesses listed below? Current treatment/ medication? If yes, what year did treatment/medication start? Mark No if you have not had the ailment. Blood disease? No Yes No Yes Year... Arthritics? No Yes No Yes Year... Rheumatism? No Yes No Yes Year... Muscle disease? No Yes No Yes Year... Neurological diseases No Yes No Yes Year... (e.g. epilepsy, MS)? Psychiatric problems? No Yes No Yes Year... Other... No Yes No Yes Year No, I have none of the above ailments. 9

10 32. Have you at any time in the last six months been admitted to the hospital? No Yes If Yes, indicate the number of times you have been admitted:... If Yes, which hospital(s) and for what reason? Do you take any medication regularly (including painkillers, spray, eye drops, insulin shots, oral contraceptives, herbal medicines)? No Yes If you answered Yes, write the name and dosage of the medication and how often you take it. Name of medication Dosage How often do you take it? 34. Have you taken cortisone tablets at any time during the last three months? No Yes 35. Have you ever been given a local or general anesthetic? No Yes If yes, did any problems occur? No Yes If problems occurred, describe: Have any of your relatives ever experienced problems with anesthesia? No Yes 37. If you have answered Yes to questions about previous diseases or operations in any of the questions above, do you give your consent to those files being accessed in connection with this operation? Yes No 38. It is also important for us to know if you have any other requirements/problems that might influence your care. Do you have any of the problems/needs listed below? Yes No If yes, which? I have aches and/or pain I have impaired hearing I have impaired eyesight I am physically disabled I need an interpreter 10

11 39 Did you have difficulty understanding any of the questions in this questionnaire? Yes No If Yes, write the number of the question(s) and describe the problem: 40 Is there anything else you can think of that might be important for us to know? 41. In conclusion, we would like to ask you to summarize, in one sentence, the main reason you are undergoing surgery How would you prefer to fill in the next questionnaire? Online (Please fill in your address on the first page.) Paper copy No preference (Please fill in your address on the first page.)... Name (of the person who has filled in the questionnaire) 11