Pulmonary Rehabilitation with the Addition of Maintenance Sessions (PRAMS) Study

Patient ID / Patient Initials / Centre No
Visit / Date / / /

Cost Questionnaire – follow up

These questions help us to understand how your COPD affects your use of health services and how much your COPD 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 your have used a service or how much you have spent since your last follow-up which was on ___ / ___ / ___. If you cannot remember things exactly please give your best estimate. Feel free to add any of your own notes.

Hospital services

1. a) Since your last follow-up, how many times have you been to hospital

because of your COPD? for other reasons?

For an outpatient appointment
For a daycase appointment
Admitted as an inpatient

b) If you had one or more inpatient stays, how many nights did you stay at the last visit? ______

Community health services

2. Since your last follow-up, how many times have you consulted your GP

because of your COPD? for other reasons?

at the surgery
at home
over the phone

3. Since your last follow-up, how many times have you consulted a nurse from your local surgery

because of your COPD? for other reasons?

at the surgery
at home
over the phone

4. Since your last follow-up, have you seen any of the following NHS health care professionals:

for for other For each, please provide number of:

COPD? reasons? surgery/practice visits home visits phone calls

Health visitor /  / 
Physiotherapist /  / 
Occupational therapist /  / 
Other / Specify /  / 

5. Since your last follow-up, how many times have you seen someone from social services or used any of their services? e.g. social worker, home help, care attendant, meals on wheels, occupational therapist

for for other For each, please provide number of:

Person or service COPD? reasons? office visits home visits phone calls

 / 
 / 
 / 

Private health care

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

for for other For each, please provide total amount spent

Person seen COPD? other reasons? on treatment since last follow-up

 /  / £
 /  / £

7. Since your last follow-up have you paid for any private health care?

for for other For each, please provide total amount spent

Person seen COPD? reasons? on treatment since last follow-up

 /  / £
 /  / £

Medications and equipment

8. Since your last follow-up, have you paid for any non-prescription medications or complementary remedies? e.g. painkillers, cold remedies, vitamins, minerals, herbal remedies

Name of product / Total spent on product over last three months
£
£
£
£

Pulmonary Rehabilitation with the Addition of Maintenance Sessions (PRAMS) Study

Patient ID / Patient Initials
Assessment / Date / / /

9. Since your last follow-up have you been issued with or bought any health aids, devices or equipment?

e.g. walking sticks, wheel chairs, home adaptations

item own cost OR from: GP Social services Hospital

for your COPD? /   
  
  
for other reasons? /   
  

Phone calls

9. Since your last follow-up, around how many phone calls have you made to any health services (excluding any you have already mentioned in previous questions)?

Days off

10. Since your last follow-up, around how many days have you been off work or unable to perform your normal activities

because of your COPD? / days / for other reasons? / days

Carers & assistance with activities of daily living

11. Does anyone (such as a spouse/partner, family member or friend) care for you or assist you with daily activities, for example self care (dressing, using the toilet), eating or drinking, household chores and shopping or household management (e.g. opening mail, managing bank accounts)?

Yes  No 

If yes, please indicate which activities you have help with:

Self care (dressing, using the toilet etc.) 

Eating or drinking 

Household chores (cleaning, gardening, shopping etc.) 

Household management (opening the mail, managing bank accounts) 

Other (please specify ______) 

If yes, for approximately how many hours per day in total do you receive help for? ______hours per day.

And how many days per week do you normally receive care for? _____ days per week

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Version 2 14/7/09