Uk ibdq

Patient Quality of Life
Questionnaire (baseline)
PLEASE DO NOT WRITE ON THIS QUESTIONNAIRE.
IT IS FOR INFORMATION ONLY. ALL ANSWERS WILL BE RECORDED BY THE RESEARCH PROFESSIONAL The CONSTRUCT study Biobank Suite (rm 244), Grove Building, School of Medicine, Swansea University Singleton Park, Swansea SA2 8PP Phone: +44(0)1792 513426 Fax: +44 (0)1792 513423 Swansea University School of Medicine
Grove Building Singleton Park, Swansea SA2 8PP Phone: +44(0)1792 513426 Fax: +44 (0)1792 513423 Email: [email protected] Section E: Resource use questionnaire

This section is about the health care you have received – apart from any services
at the hospital where you were recruited.
All questions refer to the three months before completing this questionnaire.
We would like to know about contacts you have had with health professionals in the last
three months for any reason - not just with regard to your bowel condition.

1. In the last 3 months, have you been seen for any reason by any of the following at
your GP surgery?
 Your own or another GP  Nurse  Any other health professional (e.g. dietician, physiotherapist, health visitor) Please go to Question 2 Please enter the number of times for… Your own or another GP Other (please specify)

2. In the last 3 months, have you been seen for any reason by any of the following at
home?
 Your own or another GP
 Nurse
 Any other health professional (e.g. dietician, physiotherapist, health visitor)
Please go to Question 2 Please enter the number of times Your own or another GP Other (please specify)

3. In the last 3 months, have you discussed your health over the telephone with any
Swansea University School of Medicine
Grove Building Singleton Park, Swansea SA2 8PP Phone: +44(0)1792 513426 Fax: +44 (0)1792 513423 Email: [email protected] health professional (apart from to make or change appointments). No Please to to Question 4 Yes Please enter number of times With anyone at your GP surgery With anyone at the hospital With NHS Direct (NHS 24 in Scotland)
4. In the last 3 months, have you visited an accident and emergency department
other than at the hospital where you were recruited to the study?
Please go to Question 4 Please enter the number of times

n the last 3 months, have you been admitted as an in-patient (i.e. stayed overnight in
hospital) for any reason at a hospital other than at the hospital whereyou were
recruited to the study?
Please go to Question 5 Please enter the number of nights you spent in hospital
6If you are in work, did you take any time off work either due to illness or in
order to see any health professional, for any reason, in the last 3 months?
Please go to Section F Please enter the number of day (to the nearest half day)
Swansea University School of Medicine
Grove Building Singleton Park, Swansea SA2 8PP Phone: +44(0)1792 513426 Fax: +44 (0)1792 513423 Email: [email protected] Section F: Drugs use questionnaire
Have you taken any of the following prescribed drugs in the last 3 months?
Drugs for colitis (prescribed in the last 3 months)
Name of Drug
Strength
Number Frequency Tick if taken
*For PRN drugs, record instead the average number taken per day and average frequency
(Nº of days per week) **For oral prednisolone with reducing dose, please record details Swansea University School of Medicine
Grove Building Singleton Park, Swansea SA2 8PP Phone: +44(0)1792 513426 Fax: +44 (0)1792 513423 Email: [email protected] Suppositories for colitis (prescribed in the last 3 months)
Strength
No Suppositories
If not continuous,
for how many days
Enemas for colitis (prescribed in the last 3 months)
Swansea University School of Medicine
Grove Building Singleton Park, Swansea SA2 8PP Phone: +44(0)1792 513426 Fax: +44 (0)1792 513423 Email: [email protected] Medication for general GI disorders (prescribed in the last 3 months)
Name of Drug
Strength
Frequency
(Peppermint oil) (Ispaghula husk) (Metoclopramide) *For PRN drugs, record instead the average number taken per day and average frequency (Nº of
Medication not listed (prescribed in the last 3 months)
Have you been prescribed any other drugs regularly in the last 3 months that have
Swansea University School of Medicine
Grove Building Singleton Park, Swansea SA2 8PP Phone: +44(0)1792 513426 Fax: +44 (0)1792 513423 Email: [email protected] not been listed here (excluding paracetamol, aspirin and ibuprofen)? If so, please tell us the:  strength
 number of tablets you take per dose and dose frequency (e.g. two
tablets four times a day, etc)

If the medication is not taken continuously over the last three months, please tell us
whether it is taken "as required" or whether it was a short course.
Please also indicate the average number taken per day and the average frequency (No
days per week) for drugs taken "as required" or the number of days it was taken for if a
short course.
Thank you for completing this questionnaire.
If you are diagnosed with acute severe ulcerative colitis, you may be eligible for the
CONSTRUCT drugs treatment trial. If you consent to participate into the trial, you may
be asked to take part in a telephone interview with a researcher.
Please indicate below if you are happy to be asked about taking part in a telephone
interview, should you take part in the drugs trial.
Yes, I am happy to be asked about taking part in a telephone interview No, I am not happy to be asked about taking part in a telephone interview Swansea University School of Medicine
Grove Building Singleton Park, Swansea SA2 8PP Phone: +44(0)1792 513426 Fax: +44 (0)1792 513423 Email: [email protected]

Source: http://www.dirum.org/assets/downloads/634429653844459948-CONSTRUCT%20Questionnaire.pdf