Patient Questionnaire (04/02/10, Version 2.0)
1. Is this your first appointment at the gastroenterology outpatient department?
□ Yes□ No
2. Have you been diagnosed as having a medical condition affecting your gastrointestinal tract?
□ Yes (Please state) ...... □ No
3a. What are the key symptoms that you get as a result of your condition (please circle those which apply, below):
Abdominal pain / Heartburn / FatigueNausea / difficulty swallowing / Joint pains
Vomiting / Wind / Headaches
Diarrhoea / Bloating / shortness of breath
Constipation / rectal bleeding / chest pain
Other (please list these)......
3b.How severe would you say each symptom is on a scale of 1-5, 1=not severe, 5=unbearable. (Write your rating by each symptom above)
4. On average, how often do you get typical symptoms of this condition (Please fill in the no. of episodes and cancel timeframe as appropriate e.g. _ 4 times per day/week/month/yr): _ _ times per day/wk/month/year
5. Have you lost any weight since being diagnosed with your condition?
□ Yes (How much ______lb/kg) □ No
6. Do you take any dietary supplements, e.g. vitamins? □ Yes□ No
7a. Do you feel that your diet plays an important role in relation to your condition?
□ Yes (please give reason for belief below)□ No
□ Advised by family/friend□ Advised by Doctor
□ Media (e.g. television, newspaper, magazine)□ Personal experience
□ Advised by other healthcare professional (Please state): ......
□ Cannot remember reason for belief(Note: please tick as many as are applicable)
7b. If you answered ‘yes’ to question 7a, to what degree do you feel diet plays a role in your condition? (Please circle one of the numbers below, where 1 = very little influence and 10 = A lot of influence) 1 – 2 – 3 – 4 – 5 – 6 – 7 – 8 – 9 – 10
7c. If you answered ‘yes’ to question 7a, what role do you believe your diet plays in relation to your symptoms?
□ Makes better□ Worsens□ Both□ Don’t know
8. Has your view about the importance of diet changed since developing your symptoms?
□ Yes (Please explain this below) □ No
......
9. Do you avoid any foods because of your condition?
□ Yes (please state the foods you avoid and what symptom each affects below) □ No
......
10. Do you eat more of any foods because they help with your condition?
□ Yes (please state the foods you eat more of and whatsymptom each improves below) □ No
......
11. Do you think any food triggered your initial symptoms/currently causes flare ups?
□ Yes (Please specify below. By each food, please state what symptom(s) it caused/causes) □ No
......
12. Do you have any other specific beliefs about how your diet impacts on your condition?
□ Yes (Please state these below)□ No
......
13. How healthy do you think your diet is?
□ Very Healthy □ Fairly healthy □ Fairly unhealthy□ Very unhealthy
14a. Do you regularly eat breakfast?□ Yes□ No
14b. Do you regularly eat lunch?□ Yes□ No
14c. Do you regularly eat an evening meal?□ Yes□ No
14d. How often do you eat ‘on the run’?
□ Often□ Sometimes□ Occasionally□ Never
15. How would you rate your current knowledge about diet and nutrition?
□ Poor□ Fair□ Good
16. Are there any dietary changes that you have not been/think you will not be able to make?
□ Yes (Please state and give reason below)□ No
......
17. How interested are you in receiving dietary advice today?
□ Not interested □ A little bit interested □ Fairly interested □ Very interested
18. Do you expect your Doctor to ask you about your diet today?□ Yes □ No
19. Do you expect your Doctor to provide you with dietary advice today? □ Yes □ No
20. Have you, in the past, received any dietary advice?
□ Yes (Please explain the nature of the advice you received below)□ No
......
21. If you answered ‘yes’ to question 20, who provided you with this Advice?
□ General practitioner
□ Dietician
□ Gastroenterologist
□ Other (please state)……………………………………………………..
22. If you answered ‘yes’ to question 20, did you adhere to this advice?
□ Yes□ No (Please give reason below)
□Recommended dietary changes were too expensive
□Recommended dietary changes were not appetising
□Already felt my diet was adequate
□Was not convinced that dietary changes would make a difference to my symptoms
□Did not notice any change in my symptoms with recommended diet
□Other (Please explain) ……........
23. From which of the following healthcare professionals do you expect to receive dietary advice?
□ General practitioner
□ Dietician
□ Gastroenterologist
□ Other (please state)……………………………………………………..
24. Would you like to be informed of the results of this study?
□ Yes (Please provide an e-mail/mailing address at the bottom of the page)□ No