The Socioeconomic Cost of Chronic Rhinosinusitis (SoCCoR) Study
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1 UEA Office Use only Local Ref Please try to fill in ALL parts of the questionnaire, even if you do not have sinus problems and do not feel they are directly relevant to you. The Socioeconomic Cost of Chronic Rhinosinusitis (SoCCoR) Study Follow-up questionnaire pack FOR DOCTOR TO COMPLETE RECRUITMET SITE CRS WITHOUT POLYPS JPUH QEHB CRS WITH POLYPS RSCH UH COFIRMED/SUSPECTED AFRS COTROL COFIRMATIO OF DIAGOSIS WITH CT SCA EDOSCOPY GSTH Other Other, please specify FH Please return the questionnaire to the orwich Medical School, UEA, orwich - for the attention of Mr Carl Philpott Follow-up pack including follow-up 1.4, EQ-5D and SOT-22 Page 1 of 7
2 The Socioeconmic Cost of Chronic Rhinosinusitis (SoCCoR) Study Assessment Follow up Date D D / M M / Y Y Y Y These questions help us to understand how your chronic rhinosinusitis (CRS) affects your use of health services and how much your chronic rhinosinusitis costs you and your family. Please read the questions carefully and tick the relevant boxes or provide information when requested. All the questions ask you how many times you have used a service or how much you have spent since your last follow-up which was on D D / M M / Y Y If you cannot remember things exactly please give your best estimate. Feel free to add any of your own notes. A) Hospital services 1. Since your last follow-up, how many times have you been in hospital? because of your CRS? for other reasons? For an outpatient appointment For a daycare appointment Admitted as an inpatient (no.of nights) o. of ights B) Community health and social services 2. Since your last follow-up, how many times have you consulted your GP? At the Surgery At home Over the phone because of your CRS? for other reasons? 3. Since your last follow-up, how many times have you consulted a nurse from your local surgery? At the Surgery At home Over the phone because of your CRS? for other reasons? 4. Since your last follow-up, have you seen any of the following HS health care professionals? Health visitor Physiotherapist Occupational therapist Other for your CRS? for other reasons? For each, please provide number of surgery/practice visits home visits phone calls Other please specify 5. How many prescriptions have you paid for...for CRS for other diseases (exempt from charges) SoCCoR Followup 1.4 Page 2 of 7
3 C) Private and Alternative Healthcare For each, please provide total amount spent on treatment since last follow-up other reasons? 6. Since your last follow-up, how many times have you seen a complementary therapist or alternative medicine practitioner? e.g. acupuncturist, homeopath, chiropractor, osteopath, reflexologist, naturopath? Type of practitioner seen (and no of times) o. of times? Amount paid for your CRS? Amount paid for other reasons? 7. Since your last follow-up, have you paid for any private health care? Type of practitioner seen (and no of times) o. of times? Amount paid for your CRS? Amount paid for other reasons? D) Medications and equipment 8. Since your last follow-up, have you paid for any non-prescription ("over the counter") medicines under the following categories (for any reason, not just your CRS - use approximate costs) Pain killers (e.g. paracetamol, aspirin) ame of product Cold and 'flu remedies (e.g. 'flu powders, decongestant tablets or inhaltion remedies, cough sweets/syrups) ame of product SoCCoR Followup 1.4 Page 3 of 7
4 asal sprays (e.g. beclomethasone, sinus rinses) ame of product Other (e.g. vitamins & minerals) ame of product E) Phone calls 10. Since your last follow-up, around how many phone calls have you made to any health or social services (excluding any you have already told us about in previous questions (4,6 & 7)? F) Days off 11. Since your last follow-up, around how many days have you been off work and/or unable to perform your normal activities because of your CRS? (days) for other reasons? (days) SoCCoR Followup 1.4 Page 4 of 7
5 Under each heading, please tick the OE box that best describes your health TODAY Mobility I have no problems in walking about I have slight problems in walking about I have moderate problems in walking about I have severe problems in walking about I am unable to walk about Self-Care I have no problems washing or dressing myself I have slight problems washing or dressing myself I have moderate problems washing or dressing myself I have severe problems washing or dressing myself I am unable to wash or dress myself USUAL ACTIVITIES (e.g. work, study, housework, family or leisure activities) I have no problems doing my usual activities I have slight problems doing my usual activities I have moderate problems doing my usual activities I have severe problems doing my usual activities I am unable to do my usual activities Pain/Discomfort I have no pain or discomfort I have slight pain or discomfort I have moderate pain or discomfort I have severe pain or discomfort I have extreme pain or discomfort Anxiety/Depression I am not anxious or depressed I am slightly anxious or depressed I am moderately anxious or depressed I am severely anxious or depressed I am extremely anxious or depressed EQ - 5D TM Page 5 of 7
6 We would like to know how good or bad your health is TODAY. This scale is numbered from 0 to means the best health you can imagine. 0 means the worst health you can imagine. Mark an X on the scale to indicate how your health is TODAY. ow, please write the number you marked on the scale in the box below. YOUR HEALTH TODAY EQ - 5D TM Page 6 of 7
7 Snot - 22 Questionnaire ISTRUCTIOS Below you will find a list of symptoms and social/emotional consequences of your nasal disorder. We would like to know more about these problems and would appreciate your answering the following questions to the best of your ability. There are no right or wrong answers and only you can provide us with this information. Please rate your problems over the last two weeks. Considering how severe the problem is when you experience it and how frequently it happens, please rate each item below on how "bad" it is by filling in the box that corresponds to how you feel. (Fill one box only per item) Then, pick the 5 that are the most important items affecting your health and fill in the corresponding box in the grey column on the right. o Problem Very mild Mild or slight Moderate Severe As bad as it could be Most important Item (Pick 5) eed to blow nose Sneezing Runny nose asal obstruction Loss of smell or taste Cough Post-nasal discharge Thick nasal discharge Ear fullness Dizziness Ear Pain Facial pain/pressure Difficulty falling asleep Wake up at night Lack of good night's sleep Wake up tired Fatigue Reduced productivity Reduced concentration Frustrated/restless/irritable Sad Embarrassed SOT - 22 Thank you for taking part in this survey Page 7 of 7
The Socioeconomic Cost of Chronic Rhinosinusitis (SoCCoR) Study
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