DATA COLLECTION SHEET CRF 3M FOLLOW UP AT 3 MONTHS (+/- 2 weeks)
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1 DATA COLLECTION SHEET CRF 3M FOLLOW UP AT 3 MONTHS (+/- 2 weeks) Center ID: Patient code: Date of evaluation (dd/mm/yyyy): / / 90 day mortality No Yes Date of death (dd/mm/yyyy): / / (If Yes specify cause of death: and living situation at that time home independent home with family/care giver residential care in-hospital Medicine/Rehabilitation facility) Living situation: home independent home with family/care giver residential care inhospital Medicine/Rehabilitation facility Has the patient been enrolled in a Rehabilitation program? Yes (home/outpatient) Yes (Rehab facility) No Did the patient receive any postoperative nutritional supplement? Yes ( Oral Enteral Parenteral) Postoperative chemotherapy: Yes No No If yes specify start date (dd/mm/yyyy): / / end date (dd/mm/yyyy): / / Unplanned interruption of treatment Yes No Postoperative radiation therapy: Yes No If yes specify start date (dd/mm/yyyy): / / end date (dd/mm/yyyy): / / Unplanned interruption of treatment Yes No Geriatrician involved in postoperative care? Yes No
2 NUTRITIONAL RISK SCREENING Weight in kg:. Height in cm:. BMI: (weight/height x height) Mildly impaired nutritional status: >5% weight loss in 3 months or food intake below 50-75% of normal requirement in preceding week Moderately impaired nutritional status: >5% weight loss in 2 months or BMI impaired general condition or food intake 25-60% of normal requirement in preceding week Severely impaired nutritional status: Nutritional Status Score Normal 0 Mildly impaired 1 Moderately impaired 2 Severely impaired 3 Instructions: circle appropriate score >5% weight loss in 1 month (>15% in 3 months) or BMI < impaired general condition or food intake 0-25% of normal requirement in preceding week TUG test first trial (sec) TUG test second trial (sec) 90 day morbidity (Clavien-Dindo) Complications Gr I Gr II Gr IIIa Gr IIIb Gr IVa Gr IVb Gr V d Respiratory Cardiac Renal Neurological Nutritional Pressure sores Analgesic problems
3 Delirium Wound Others Gr = grade d= if the patient suffers from the complication at the time of discharge
4 EQ-5D-3L VAS* ADL MOBILITY I have no problems in walking about 1 I have some problems in walking 2 about I am confined to bed 3 SELF-CARE I have no problems with self care 1 I have some problems washing or 2 dressing myself I am unable to wash or dress myself 3 USUAL I have no problems with performing 1 ACTIVITIES my usual activities I have some problems with 2 performing my usual activities I am unable to do my usual activities 3 PAIN/ I have no pain or discomfort 1 DISCOMFORT I have moderate pain or discomfort 2 I have extreme pain or discomfort 3 ANXIETY/ I am not anxious or depressed 1 DEPRESSION I am moderately anxious or depressed 2 I am extremely anxious or depressed 3 Your health today: BATHING DRESSING TOILET TRANSFER CONTINENCE I = Receives no assistance (gets in and out of bath or shower by self if bath is usual means of bathing) I = Receives assistance in bathing only one part of the body (such as back or leg) D = Receives assistance in bathing more than one part of the body (or not bathed) I = Gets clothes and gets completely dressed without assistance I = Gets clothes and gets completely dressed without assistance except for assistance in tying shoe laces D = Receives assistance in getting clothes or in getting dressed, or stays partly or completely undressed I = Goes to toilet room, cleans self, and arranges clothes without assistance (may use object for support such as cane, walk frame, or wheelchair and may manage night bedpan or commode, emptying same in morning) D = Receives assistance in going to toilet room or in cleaning self or in arranging clothes after elimination or in use of night bedpan or commode D = Doesn t go to room termed toilet for the elimination process I = Moves in and out of bed as well as in and out of chair without assistance (may be using object for support such as cane or walk frame) D = Moves in and out of bed or chair with assistance D = Doesn t get out of bed I = Controls urination and bowel movement completely by self D = Has occasional accidents D = Needs supervision for urine or bowel control; catheter is used, or is incontinent * We would like to know how good or bad your health is TODAY. This scale is numbered from 0 to 100. Mark an X on the scale to indicate how your health is TODAY. 100 means the best health you can imagine 0 means the worst health you can imagine.
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