Varicose Veins Surgery Questionnaire
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1 REV_VaricoseVeins_12pp_Q_PostOp 29/10/09 Page 1 Varicose Veins Surgery Questionnaire After your operation About three months ago you had a Varicose Veins Operation. You may remember that you agreed that we could send you an After your operation questionnaire. Please can you fill in this questionnaire and return it using the provided pre-paid envelope. Thank you for your help. Q1. Is anyone helping you fill in this questionnaire? Yes 1 2 If the answer is yes, please give the relationship to you of the person assisting you Family member Healthcare e.g. spouse, Other Friend/ professional child, parent relative Carer neighbour e.g. nurse/doctor Other If you are helping to complete this questionnaire on behalf of the patient, please ensure that the information given below is that of the patient and not your own. Q2. What is your date of birth? D D M M Y Y Y Y / /
2 REV_VaricoseVeins_12pp_Q_PostOp 29/10/09 Page 2 A question about your current home circumstances Q3. Which statement best describes your living arrangements? I live with partner/spouse/family/friends 1 I live alone 2 I live in a nursing home, hospital or other long-term care home 3 Other 4 Q4. Please confirm when your varicose veins operation took place (day, month, year). 2 0 D D M M Y Y Some questions about your surgery and your health Please mark the boxes below with a tick or numbers where appropriate. If you are unsure about how to answer a question, please give the best answer you can. Q5. Did you experience any of the following problems after your operation? Please tick Yes or for each problem. Yes Allergy or reaction to drug 1 2 Urinary problems 1 2 Bleeding 1 2 Wound problems 1 2 Q6. Have you been readmitted to hospital since the operation on your varicose veins? Yes / /
3 REV_VaricoseVeins_12pp_Q_PostOp 29/10/09 Page 3 Q7. Have you had another operation on your varicose veins? Yes 1 2 Q8. In general, would you say your health is: Excellent Very good Good Fair Poor Q9. How would you describe the results of your operation? Excellent Very good Good Fair Poor Q10. Overall, how are the problems now with your varicose veins on which you had surgery, compared to before your operation? Much A little About the A little Much better better same worse worse / / 3
4 REV_VaricoseVeins_12pp_Q_PostOp 29/10/09 Page 4 The following questions relate to problems commonly associated with varicose veins. We appreciate that you may no longer have any visible varicose veins after your surgery but please try and answer each question as best you can. Q11. Do you have any visible varicose veins on your legs at the moment? Right Left Yes Q12. If Yes, please draw in your varicose veins in the diagram(s) below. If, please proceed to Q13. Legs viewed from front Legs viewed from back Right Leg Left Leg Left Leg Right Leg Q13. In the last two weeks, for how many days did your varicose veins cause you pain or ache? Right Left ne at all 1 1 Between 1 and 5 days 2 2 Between 6 and 10 days 3 3 For more than 10 days / /
5 REV_VaricoseVeins_12pp_Q_PostOp 29/10/09 Page 5 Q14. During the last two weeks, on how many days did you take painkilling tablets for your varicose veins? (Please tick one box) Q15. In the last two weeks, how much ankle swelling have you had? (Please tick one box) ne at all 1 Between 1 and 5 days 2 Between 6 and 10 days 3 For more than 10 days 4 ne at all 1 Slight ankle swelling 2 Moderate ankle swelling (e.g. causing you to sit with your feet up whenever possible) 3 Severe ankle swelling (e.g. causing you difficulty putting on your shoes) 4 Q16. In the last two weeks, have you worn support stockings or tights? Right Left 1 1 Yes, those I bought myself without a doctor s prescription 2 2 Yes, those my doctor prescribed for me which I wear occasionally 3 3 Yes, those my doctor prescribed for me which I wear every day 4 4 Q17. In the last two weeks, have you had any itching in association with your varicose veins? Right Left 1 1 Yes, but only above the knee 2 2 Yes, but only below the knee 3 3 Both above and below the knee 4 4 / / 5
6 REV_VaricoseVeins_12pp_Q_PostOp 29/10/09 Page 6 Q18. Do you have purple discolouration caused by tiny blood vessels in the skin, in association with your varicose veins? Right Left Q19. Do you have a rash or eczema in the area of your ankle? Right Left Yes Yes, but it does not require any treatment from a doctor or district nurse 2 2 Yes, and it requires treatment from my doctor or district nurse 3 3 Q20. Do you have a skin ulcer associated with your varicose veins? Right Left 1 1 Yes 2 2 Q21. Does the appearance of your varicose veins cause you concern? (Please tick one box) Yes, their appearance causes me slight concern 1 2 Yes, their appearance causes me moderate concern 3 Yes, their appearance causes me a great deal of concern Q22. Does the appearance of your varicose veins influence your choice of clothing including tights? (Please tick one box) 1 Occasionally 2 Often 3 4 Always 4 6 / /
7 REV_VaricoseVeins_12pp_Q_PostOp 29/10/09 Page 7 Q23. During the last two weeks, have your varicose veins interfered with your work/housework or other daily activities? (Please tick one box) 1 I have been able to work but my work has suffered to a slight extent 2 I have been able to work but my work has suffered to a moderate extent 3 My veins have prevented me from working one day or more 4 Q24. During the last two weeks, have your varicose veins interfered with your leisure activities (including sport, hobbies and social life)? (Please tick one box) 1 Yes, my enjoyment has suffered to a slight extent 2 Yes, my enjoyment has suffered to a moderate extent 3 Yes, my veins have prevented me taking part in any leisure activities 4 / / 7
8 REV_VaricoseVeins_12pp_Q_PostOp 29/10/09 Page 8 By placing a tick in one box in each group (Questions 25 29) below, please indicate which statements best describe your own health state today. Q25. Mobility I have no problems in walking about 1 I have some problems in walking about 2 I am confined to bed 3 Q26. Self-Care I have no problems with self-care 1 I have some problems washing or dressing myself 2 I am unable to wash or dress myself 3 Q27. Usual Activities (e.g. work, study, housework, family or leisure activities) I have no problems with performing my usual activities 1 I have some problems with performing my usual activities 2 I am unable to perform my usual activities 3 Q28. Pain/Discomfort I have no pain or discomfort 1 I have moderate pain or discomfort 2 I have extreme pain or discomfort 3 Q29. Anxiety/Depression I am not anxious or depressed 1 I am moderately anxious or depressed 2 I am extremely anxious or depressed 3 8 / /
9 REV_VaricoseVeins_12pp_Q_PostOp 29/10/09 Page 9 Q30. To help people say how good or bad a health state is, we have drawn a scale (rather like a thermometer) on which the best state you can imagine is marked 100 and the worst state you can imagine is marked 0. We would like you to indicate on this scale how good or bad your own health is today, in your opinion. Please do this by drawing a line from the box below to whichever point on the scale indicates how good or bad your health state is today. Best imaginable health state Your own health state today Worst imaginable health state / / 9
10 REV_VaricoseVeins_12pp_Q_PostOp 29/10/09 Page 10 Q31. Today s date (day, month, year) 2 0 D D M M Y Y Q32. Do you consider yourself to have a disability? Yes 1 2 Thank you for your assistance. Please return this questionnaire in the envelope provided. You do not have to use a stamp the postage is already paid. 10 / /
11 REV_VaricoseVeins_12pp_Q_PostOp 29/10/09 Page 11 blank page
12 REV_VaricoseVeins_12pp_Q_PostOp 29/10/09 Page 12 Contact us for further details: Freephone: Write: PROMs Survey, PO Box 909, Aylesbury, HP22 9HT Website: Crown copyright Except where expressly stated to the contrary, this questionnaire is protected by Crown copyright. Any and all copyrights in question 5 vest in London School of Hygiene and Tropical Medicine. Any and all copyrights in questions 25 30, their order, layout, and images printed on page 9 vest in the EuroQol Group. The EuroQol Group reserves all rights EuroQol Group. EQ-5D TM is a trademark of the EuroQol Group.
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