Questionnaire given to patient to assess their upper and lower gastrointestinal symptoms, genitourinary symptoms, and quality of life scores.
Supporting Information:
Questionnaires used:
GES AND INTERSTIM DEVICE
Name______MR#______Date______
Circle the number that best correlates your symptom severity before the gastric stimulator was placed with 0-being best and 4-being worse:
Vomiting 0 1 2 3 4
Nausea 0 1 2 3 4
Stomach feels full with small amounts of food 0 1 2 3 4
Abdominal pain 0 1 2 3 4
Bloating 0 1 2 3 4
Now after your gastric stimulator was placed:
Vomiting 0 1 2 3 4
Nausea 0 1 2 3 4
Stomach feels full with small amounts of food 0 1 2 3 4
Abdominal pain 0 1 2 3 4
Bloating 0 1 2 3 4
In regards to your bowel habits: (Scale 0-3)
Circle the frequency that best correlates your symptoms before the Interstim (bladder stimulator) was placed:
Incontinence of Stool None Occasionally Half of the time All of the time
Having to rush to go to bathroom None Occasionally Half of the time All of the time
(Urgency)
Constipation None Occasionally Half of the time All of the time
How many bowel movements do you have per week? ______
Now after your Interstim was placed (Scale 0-3)
Incontinence of Stool None Occasionally Half of the time All of the time
Having to rush to go to bathroom None Occasionally Half of the time All of the time
(Urgency)
Constipation None Occasionally Half of the time All of the time
How many bowel movements do you have per week? ______
In regards to your bladder problems (if any): (Scale 0-3)
Circle the frequency that best correlates your symptoms before the Interstim (bladder stimulator) was placed:
Difficulty Voiding None Occasionally Half of the time All of the time
Trouble Starting Urinary Stream None Occasionally Half of the time All of the time
Straining to Urinate None Occasionally Half of the time All of the time
Having to rush to go to bathroom None Occasionally Half of the time All of the time
(Urgency)
Leakage of Urine (Incontinence) None Occasionally Half of the time All of the time
If you had to use incontinence pads how many did you use on average per day: ______
Now after your Interstim was placed:
Difficulty Voiding None Occasionally Half of the time All of the time
Trouble Starting Urinary Stream None Occasionally Half of the time All of the time
Straining to Urinate None Occasionally Half of the time All of the time
Having to rush to go to bathroom None Occasionally Half of the time All of the time
(Urgency)
Leakage of Urine (Incontinence) None Occasionally Half of the time All of the time
If you had to use incontinence pads how many did you use on average per day: ______
4. Quality of Life
How do you characterize your quality of life (feeling happy about your overall self), please circle one number on a scale from -3 if very unhappy up to +3 with very happy?
Before Gastric Stimulator:
-3 -2 -1 0 +1 +2 +3
After Permanent Gastric Stimulator (Present time):
-3 -2 -1 0 +1 +2 +3
Before Interstim (bladder stimulator):
-3 -2 -1 0 +1 +2 +3
After Permanent Interstim (Present):
-3 -2 -1 0 +1 +2 +3
Before Both Stimulators:
-3 -2 -1 0 +1 +2 +3
After Both Stimulators (Present):
-3 -2 -1 0 +1 +2 +3