Questionnaire for Women Who Have Had

Patient ID:______

Questionnaire for women who have had

a total hysterectomy

One year after the operation.

How to answer the questionnaire.

Before answering please read the entire question, including the text as well as the possible answering categories.

Most questions should be answered by putting a ring around the number that belongs to the answer you have chosen.

Example:

1)In general, would you say that your health is:

Put one ring

Excellent 1

Very good 2

Good 3

Fair 4

Poor 5

For other questions rings should be put around numbers in a table.

Example:

4) During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health?

Put a ring in each line

Yes / No
Cut down on the amount of time you spent on work or other activities / 1 / 2
Accomplished less than you would like / 1 / 2
Were limited in the kind of work or other activities / 1 / 2
Had difficulties performing the work or other activities (for example, it took extra effort) / 1 / 2

Please return the filled out questionnaire in the enclosed envolope within ten days. The letter is post free.

If you wish to withdraw from the trial and therefore do not wish to answer the questionnaire, please put a ring on the last page of the questionnaire and return the questionnaire anyway. This way you avoid receiving a reminder in three weeks.

Thank you for your help.

The first part of the questionnaire is about your own perception of your health.

In general, would you say that your health is:

Put one ring

Excellent 1

Very good 2

Good 3

Fair 4

Poor 5

______

Compared to one year ago, how would you rate your health in general now?

Put one ring

Much better now 1

Somewhat better now 2

About the same 3

Somewhat worse now 4

Much worse now 5

______

The following questions are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?

Put one ring in each line

Yes,
limited a lot / Yes, limited a little / No, not limited at all
Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports / 1 / 2 / 3
Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf / 1 / 2 / 3
Lifting or carrying groceries / 1 / 2 / 3
Climbing several flights of stairs / 1 / 2 / 3
Climbing one flight of stairs / 1 / 2 / 3
Bending, kneeling or stooping / 1 / 2 / 3
Walking more than a mile / 1 / 2 / 3
Walking several blocks / 1 / 2 / 3
Walking one block / 1 / 2 / 3
Bathing or dressing yourself / 1 / 2 / 3

______

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?

Put one ring in each line

______

During the past 4 weeks, have you had any of the following problems with your work or other regular activities as a result of any emotional problems (such as feeling depressed or anxious)?

Put one ring in each line

Yes / No
Cut down on the amount of time you spent on work or other activities / 1 / 2
Accomplished less than you would like / 1 / 2
Didn't do work or other activities as carefully as usual / 1 / 2

______

During the past 4 weeks, to what extent has your physical health or emotional problems interfered with your normal social activities with family, friends, neighbors, or groups?

Put one ring

Not at all 1

Slightly2

Moderately3

Quite a bit4

Extremely5

______

How much bodily pain have you had during the past 4 weeks?

Put one ring

None1

Very mild2

Mild3

Moderate4

Severe5

Very severe6

______

During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the house and housework)?

Put one ring

Not at all1

A little bit2

Moderately3

Quite a bit4

Extremely5

______

These questions are about how you feel and how things have been with you 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……

Put one ring in each line

All of the time / Most of the time / A good bit of the time / Some of the time / A little of the time / None of the time
Did you feel full of pep? / 1 / 2 / 3 / 4 / 5 / 6
Have you been a very nervous person? / 1 / 2 / 3 / 4 / 5 / 6
Have you felt so down in the dumps that nothing could cheer you up? / 1 / 2 / 3 / 4 / 5 / 6
Have you felt calm and peaceful? / 1 / 2 / 3 / 4 / 5 / 6
Did you have a lot of energy? / 1 / 2 / 3 / 4 / 5 / 6
Have you felt downhearted and blue? / 1 / 2 / 3 / 4 / 5 / 6
Did you feel worn out? / 1 / 2 / 3 / 4 / 5 / 6
Have you been a happy person? / 1 / 2 / 3 / 4 / 5 / 6
Did you feel tired? / 1 / 2 / 3 / 4 / 5 / 6

______

During the past 4 weeks, how much of the time has your physical health or your emotional problems interfered with your social activities (like visiting friends, relatives, etc.)?

Put one ring

All the time1

Most of the time2

Some of the time3

A little of the time4

None of the time5

______

How TRUE or FALSE is each of the following statements for you?

Put one ring in each line

Definitely true / Mostly true / Don't know / Mostly false / Definitely false
I seem to get sick a little easier than other people / 1 / 2 / 3 / 4 / 5
I am as healthy as anybody I know / 1 / 2 / 3 / 4 / 5
I expect my health to get worse / 1 / 2 / 3 / 4 / 5
My health is excellent / 1 / 2 / 3 / 4 / 5

______

The nex questions are about pelvic pain.

During the past 4 weeks, have you suffered from pelvic pain?

Put one ring

Yes1

No2

______

During the past 4 weeks, has one or more of the following situations given rise to your pelvic pain?

Put one or more rings

Menstrual period1

Intercourse1

Physical activities1

Other______1

I don't suffer from pelvic pain1

______

During the past 4 weeks, has one or more of the following situations increased your pelvic pain?

Put one or more rings

Menstrual period1

Intercourse1

Physical activities1

Other______1

I don't suffer from pelvic pain1

______

Does pelvic pain interfere with your daily activities?

Put one ring

Yes1

No2

I don't know3

______

After the operation, has your pelvic pain changed?

Put one ring

Yes, it has disappeared1

Yes, it has decreased2

No, it is unchanged3

Yes, it has increased4

______

The questions in the next paragraph are about menopause.

Do you think that you have passed menopause?

Put one ring

Yes1

No2

I don't know3

______

During the past 12 months, have you been bothered by one or more of the following symptoms?

Put one or more rings

Dryness of the vagina1

Hot flushes1

Nightly flushes1

Mood swings1

Experience difficulty focusing1

None of the above1

I don't know 1

______

Do you take HRT or birth control pills? Also put a ring around "Yes", if you use hormone plaster, hormone gel, hormone crème, or hormone vagitories.

Put one ring

Yes1

No2

______

Please, write the name of your hormone therapy? Please, also write the name, if it is hormone plaster, hormone gel, hormone creme, hormone vagitories or birth control pills.

______

During 24 hours, how many times do you usually have to pass water?

Put one ring

1 - 3 times1

4 - 6 times2

7 - 10 times3

More than 10 times4

______

At night, do you have to get out of bed to pass water?

Put one ring

Yes1

No2

______

At night, how many times do you have to pass water?

Put one ring

Never1

Not every night2

1 - 2 times per night3

More than twice per night4

______

Do you experience pain passing the water?

Put one ring

Yes1

No2

______

Please, describe your pain passing the water?

Put one ring

Extreme 1

Quite a bit2

Moderate3

Slight4

No pain at all5

______

During the past year, how often did you experience urinary tract infection?

Put one ring

All the time1

Often2

Every now and then3

Rare4

Never5

______

Do you have the feeling of incomplete bladder emptying, while passing the urine?

Put one ring

Never1

Rare2

Often3

Always4

______

Do you have to strain to pass water?

Put one ring

Never1

Rare2

Often3

Always4

______

Please, describe the quality of your stream when passing the urine?

Put one ring

Heavy1

Normal2

Poor3

______

Do you have to do something special to empty your bladder?

Put one ring

Yes, I sometimes/always use a katheter1

Yes, I do double/triple voiding2

No3

Other______4 ______

In which situations do you usually experience urinary incontinence?

Put one or more rings

Always1

During intercourse1

During urge to pass the urine1

During cough, sneeze or laughter1

Sport or other physical activity1

Never1

______

How often does urinary incontinence interfere with your daily life?

Put one ring

Always1

Often2

Rare3

Never4

______

Does your urinary function interfere with your daily life?

Put one ring

Yes, it is a big problem1

Yes, it is a problem2

Yes, but it is only a minor problem3

No, it is no problem4

______

During the past year, did you experience descensus or prolapse of your bladder?

Put one ring

Yes1

No2

______

During the past year, did you experience descensus or prolapse/drag of your vagina?

Put one ring

Yes1

No2

______

The next questions are about your bowel function.

How often do you usually open your bowels?

Put one ring

Twice or more a day1

Once a day2

Every 2.- 3. day3

Once a week or less4

______

Do you need to use laxatives to open your bowels?

Put one ring

Yes1

No2

______

Please, describe the consistency of your stools?

Put one ring

Thin1

Normal2

Hard3

______

Do you usually or often experience incontinence of flatus?

Put one ring

Yes1

No2

______

Do you usually or often experience incontinence of stool?

Put one ring

Yes1

No2

______

Do you experience pain when opening your bowels?

Put one ring

Yes1

No2

______

Does your bowel function interfere with your daily life?

Put one ring

Yes, it is a big problem 1

Yes, it is a problem2

Yes, but it is only a minor problem3

No, it is no problem4

______

During the past year, have you experienced descensus or prolapse of your bowel through your vagina?

Put one ring

Yes1

No2

______

Now some questions about your partner.

Do you have a partner?

Put one ring

Yes1

No2

______

For how long time have you had your partner?

Write the number of months or years.

______years______months

______

How is the relationship to your partner?

Put one ring

Excellent1

Good2

Fair3

Poor4

I don't know5

I don't have a partner6

______

The next questions are about your sexual life.

For many different reasons women experience varying degree of desire for sex and intercourse. Through the next pages we would like to know how things have been with you during the past year.

Do you experience pain during intercourse?

Put one ring

Yes1

No2

______

Where do you feel the pain during intercourse?

Put one or more rings

At the entrance of the vagina1

Deep in the vagina1

At the perineum1

Other______1

I don't experience pain during intercourse1

______

How often do you desire sex?

Put one ring

Almost never1

Less than once a month2

2-4 times a month3

1-2 times a week4

More than twice a week5

______

How often do you have intercourse?

Put one ring

Almost never1

Less than once a month2

2-4 times a month3

1-2 times a week4

More than twice a week5

______

Women achieve sexual satisfaction (orgasm) in many different ways. Some achieve sexual satisfaction (orgasm) through self-satisfaction (masturbation), some through intercourse and others through both acts.

______

How often do you satisfy yourself (masturbate)?

Put one ring

Never1

Less than once a year2

Less than once a month3

2-4 times a month4

1-2 times a week5

More than twice a week6

______

Do you achieve sexual satisfaction (orgasm) during intercourse?

Put one ring

Never1

Rare2

Often3

Always4

a) If you achieve satisfaction (orgasm), how does it happen?

Put one or more rings

By stimulating the clitoris1

By deep penetration of the penis1

Other______1

______

Please describe the quality of your satisfaction (orgasm)?

Put one ring

Excellent1

Good2

Fair3

I don't achieve satisfaction4

______

Are you satisfied with your sexual life?

Put one ring

Yes1

No2

I don't know3

______

Finally, some questions about your health and your work.

How much do you weigh?

______kg

______

Have you paid a visit to your doctor's during the past year?

Put one ring

Yes1

No2

I don't know3

______

What was the reason for visiting your doctor?

Please write.

______

During the past year, have you been admitted to the hospital?

Put one ring

Yes1

No2

______

What was the reason for your hospital stay?

Please write.

______

Do you take any kind of medicine daily or weekly?

Put one ring

Yes1

No2

______

What kind of medicine do you take?

Please write. Also write the name if the medicine is HRT.

______

Do you suffer from any chronic disease (disease that bothers you daily or every now and then?

Put one ring

Yes1

No2

______

Has your work changed since the operation?

Put one ring

Yes, I am working outside of home1

Yes, I am working at home2

Yes, I am on leave3

Yes, I am unemployed4

Yes, I have retired5

No6

Other______7

______

Do you know something about the operation now that you would have liked to know before the operation?

Please write.

______

Thank you for answering the questionnaire.

If you wish to make comments about questions or about the entire trial, please write them here:

I want to withdraw from the trial1

Reasons for withdrawal:

I want to withdraw on a question of principle1

I want to withdraw because of disease2

Other (please write):______3

Drawing on the front page by Ingeborg Gimbel.