Latest Posts & Tag Nicks

ASTHMA QUESTIONAIRE

April 24th, 2009 - Blog Post in Miscellaneous by Medicalinfo

0

ASTHMA QUESTIONAIRE

Name Optional

Email  Optional

1 Does anyone in your household suffer from asthma?
Yes No
2 Does anyone in your household suffer from any allegies?
 Yes No
(i.e Hayfever, ezcema, food or animal allegies.)
if yes please give details

If you answered no to the above questions you do not need to complete the rest of this questionaire.

3 What age is the Asthma sufferer

4 How often do they have an Attack?

5 Has the sufferer ever been admitted into hospital for asthma?
yes no
If yes how often?

6 Does the sufferer have a nebuliser at home?
yes no

7 If no, do you think the sufferer would benefit from one at home?
yes no
8 Has the sufferer been allergy tested?
yes no
9 Do you know what triggers there Asthma Attacks?
yes no
If yes, please give details

10 D you have any pets?
yes no
11 Do you smoke?
yes no
12 Did you smoke during your pregnancy?
yes no

Source:http://www.joshuagoodwinasthmafoundation.co.uk/sitebuildercontent/sitebuilderfiles/asthmaquestionaire.pdf

Female Sexual Function Index (FSFI)

April 23rd, 2009 - Blog Post in Miscellaneous by Medicalinfo

0

 

Female Sexual Function Index (FSFI)

 

Subject Identifier________________________ Date ________________

INSTRUCTIONS: These questions ask about your sexual feelings and responses

during the past 4 weeks. Please answer the following questions as honestly and

clearly as possible. Your responses will be kept completely confidential. In

answering these questions the following definitions apply:

Sexual activity can include caressing, foreplay, masturbation and vaginal intercourse.

Sexual intercourse is defined as penile penetration (entry) of the vagina.

Sexual stimulation includes situations like foreplay with a partner, self-stimulation

(masturbation), or sexual fantasy.

 

 

CHECK ONLY ONE BOX PER QUESTION.

Sexual desire or interest is a feeling that includes wanting to have a sexual experience, feeling receptive to a partner’s sexual initiation, and thinking or fantasizing about having sex.

1. Over the past 4 weeks, how 

Almost always or always

Most times (more than half the time)

Sometimes (about half the time)

A few times (less than half the time)

Almost never or never

2. Over the past 4 weeks, how would you rate your 

Very high

High

Moderate

Low

Very low or none at all

 

 

Sexual arousal is a feeling that includes both physical and mental aspects of sexual excitement. It may include feelings of warmth or tingling in the genitals, lubrication (wetness), or muscle contractions.

3. Over the past 4 weeks, how 

No sexual activity

Almost always or always

Most times (more than half the time)

Sometimes (about half the time)

A few times (less than half the time)

Almost never or never

4. Over the past 4 weeks, how would you rate your 

No sexual activity

Very high

High

Moderate

Low

Very low or none at all

5. Over the past 4 weeks, how 

No sexual activity

Very high confidence

High confidence

Moderate confidence

Low confidence

Very low or no confidence

6. Over the past 4 weeks, how 

No sexual activity

Almost always or always

Most times (more than half the time)

Sometimes (about half the time)

A few times (less than half the time)

Almost never or never

 

 

7. Over the past 4 weeks, how often did you become lubricated (”wet”) during sexual activity or intercourse?

No sexual activity

Almost always or always

Most times (more than half the time)

Sometimes (about half the time)

A few times (less than half the time)

Almost never or never

8. Over the past 4 weeks, how 

No sexual activity

Extremely difficult or impossible

Very difficult

Difficult

Slightly difficult

Not difficult

9. Over the past 4 weeks, how often did you 

No sexual activity

Almost always or always

Most times (more than half the time)

Sometimes (about half the time)

A few times (less than half the time)

Almost never or never

10. Over the past 4 weeks, how 

No sexual activity

Extremely difficult or impossible

Very difficult

Difficult

Slightly difficult

Not difficult

 

 

11. Over the past 4 weeks, when you had sexual stimulation or intercourse, how often did you reach orgasm (climax)?

No sexual activity

Almost always or always

Most times (more than half the time)

Sometimes (about half the time)

A few times (less than half the time)

Almost never or never

12. Over the past 4 weeks, when you had sexual stimulation or intercourse, how

No sexual activity

Extremely difficult or impossible

Very difficult

Difficult

Slightly difficult

Not difficult

13. Over the past 4 weeks, how 

No sexual activity

Very satisfied

Moderately satisfied

About equally satisfied and dissatisfied

Moderately dissatisfied

Very dissatisfied

14. Over the past 4 weeks, how 

No sexual activity

Very satisfied

Moderately satisfied

About equally satisfied and dissatisfied

Moderately dissatisfied

Very dissatisfied

 15. Over the past 4 weeks, how satisfied  have you been with your sexual relationship with your partner?

Very satisfied

Moderately satisfied

About equally satisfied and dissatisfied

Moderately dissatisfied

Very dissatisfied

16. Over the past 4 weeks, how

 

 

satisfied

have you been with your overall sexual life?

Very satisfied

Moderately satisfied

About equally satisfied and dissatisfied

Moderately dissatisfied

Very dissatisfied

17. Over the past 4 weeks, how o

Did not attempt intercourse

Almost always or always

Most times (more than half the time)

Sometimes (about half the time)

A few times (less than half the time)

Almost never or never

18. Over the past 4 weeks, how 

Did not attempt intercourse

Almost always or always

Most times (more than half the time)

Sometimes (about half the time)

A few times (less than half the time)

Almost never or never

19.Over the past 4 weeks, how would you rate your 

Did not attempt intercourse

Very high

High

Moderate

Low

Very low or none at all

 

 

Thank you for completing this questionnaire

Copyright @  2000 All Rights Reserved

level (degree) of discomfort or pain during or following vaginal penetration?often did you experience discomfort or pain following vaginal penetration?ften did you experience discomfort or pain during vaginal penetration?satisfied have you been with the amount of emotional closeness during sexual activity between you and your partner?

satisfied were you with your ability to reach orgasm (climax) during sexual activity or intercourse?difficult was it for you to reach orgasm (climax)?difficult was it to maintain your lubrication (”wetness”) until completion of sexual activity or intercourse?maintain your lubrication (”wetness”) until completion of sexual activity or intercourse?difficult was it to become lubricated (”wet”) during sexual activity or intercourse?often have you been satisfied with your arousal (excitement) during sexual activity or intercourse?confident were you about becoming sexually aroused during sexual activity or intercourse?level of sexual arousal (”turn on”) during sexual activity or intercourse?often did you feel sexually aroused (”turned on”) during sexual activity or intercourse?

level (degree) of sexual desire or interest?often did you feel sexual desire or interest?

SF -12®:

April 23rd, 2009 - Blog Post in Miscellaneous by Medicalinfo

0

 SF -12®:

This information will help your doctors keep track of how you feel and how well you are able to do your

usual activities. Answer every question by placing a check mark on the line in front of the appropriate

answer. . If you are unsure about how to answer a question, please give the best

answer you can and make a written comment beside your answer.

1. In general, would you say your health is:

_____ Excellent

_____ Very Good

_____ Good

_____ Fair

_____ Poor

The following two questions are about activities you might do during a typical day. Does YOUR

HEALTH NOW LIMIT YOU in these activities? If so, how much?

2. MODERATE ACTIVITIES, such as moving a table, pushing a vacuum cleaner, bowling, or playing

golf:

_____ Yes, Limited A Lot

_____ Yes, Limited A Little

_____ No, Not Limited At All

3. Climbing SEVERAL flights of stairs:

_____ Yes, Limited A Lot

_____ Yes, Limited A Little

_____ No, Not Limited At All

During the PAST 4 WEEKS have you had any of the following problems with your work or other regular

activities AS A RESULT OF YOUR PHYSICAL HEALTH?

4. ACCOMPLISHED LESS than you would like:

_____ Yes

_____ No

5. Were limited in the KIND of work or other activities:

_____ Yes

_____ No

 

 

 

During the PAST 4 WEEKS, were you limited in the kind of work you do or other regular activities AS A

RESULT OF ANY EMOTIONAL PROBLEMS (such as feeling depressed or anxious)?

6. ACCOMPLISHED LESS than you would like:

_____ Yes

_____ No

7. Didn’t do work or other activities as CAREFULLY as usual:

_____ Yes

_____ No

8. During the PAST 4 WEEKS, how much did PAIN interfere with your normal work (including both work

outside the home and housework)?

_____ Not At All

_____ A Little Bit

_____ Moderately

_____ Quite A Bit

_____ Extremely

The next three questions are about how you feel and how things have been DURING THE PAST 4

WEEKS. For each question, please give the one answer that comes closest to the way you have been

feeling. How much of the time during the PAST 4 WEEKS –

9. Have you felt calm and peaceful?

_____ All of the Time (1)

_____ Most of the Time (2)

_____ A Good Bit of the Time

_____ Some of the Time

_____ A Little of the Time

_____ None of the Time

 

10. Did you have a lot of energy?

_____ All of the Time (1)

_____ Most of the Time (2)

_____ A Good Bit of the Time (3)

_____ Some of the Time (4)

_____ A Little of the Time (5)

_____ None of the Time (6)

11. Have you felt downhearted and blue?

_____ All of the Time (1)

_____ Most of the Time (2)

_____ A Good Bit of the Time (3)

_____ Some of the Time (4)

_____ A Little of the Time (5)

_____ None of the Time (6)

12. During the PAST 4 WEEKS, how much of the time has your PHYSICAL HEALTH OR EMOTIONAL

PROBLEMS interfered with your social activities (like visiting with friends, relatives, etc.)?

_____ All of the Time (1)

_____ Most of the Time

_____ A Good Bit of the Time

_____ Some of the Time

_____ A Little of the Time

_____ None of the Time

 

 

 

 

SF-12® Health Survey © 1994, 2002 by Medical Outcomes Trust and QualityMetric Incorporated. All Rights Reserved

SF-12® is a registered trademark of Medical Outcomes Trust

 

EORTC IN-PATSAT32

April 23rd, 2009 - Blog Post in Miscellaneous by Medicalinfo

0

The EORTC IN-PATSAT32 is a questionnaire to assess In-patient satisfaction with care.

http://groups.eortc.be/qol/questionnaires_eortcinpatsat32.htm