Diabetic Foot Ulcer Scale: Patient

Transcription

1 Diabetic Foot Ulcer Scale: Patient INSTRUCTIONS: These questions ask about the effect that foot ulcer problems may have on your daily life and wellbeing. Please read each question carefully and think about the effect of your foot ulcer problems. nswer every question by circling one number on each line. If you are unsure about how to answer a question, please give the best answer you can.

2 1.How much have your foot ulcer problems: a)stopped you from doing the hobbies and recreational activities that you enjoy b)changed the kinds of hobbies and recreational activities that you enjoy doing c)stopped you from getting away for a holiday or a weekend break d)made you choose a different kind of holiday or short break than you would have preferred e)meant that you had to spend more planning and organizing for leisure activities Not at all little bit Moderately Quite a bit great deal

3 2.Because of your foot ulcer problems, how often have you felt: None little Some Most a)fatigued or tired b)drained c)that you had difficulty sleeping d)pain while walking or standing ll of the e)pain during the night f)unwell because of taking antibiotics or other medicine for infection* *If you have not taken antibiotics or other medicine for infection, circle None

4 3.Because of your foot ulcer problems, how often have you: a)had to depend on others to help you look after yourself (such as washing and dressing yourself) b)had to depend on others to do household chores such as cooking, cleaning or laundry c)had to depend on others to get out house d)had to spend more planning or organizing your daily life e)felt that doing anything took longer than you would have liked f)felt restricted in your daily life None little Some Most ll of the

5 4.Because of your foot ulcer problems, have you felt: a)angry because you were not able to do what you wanted to do b)frustrated by others doing things for you when you would rather do them yourself c)frustrated because you were not able to do what you wanted to do d)helpless to cure your ulcer(s) e)worried that your ulcer(s) will never heal f)worried that you may have to have an amputation g)worried about injury to your feet h)depressed because you were not able to do what you wanted to do Not at all Quite a bit Slightly Moderately Extremely

6 4.Because of your foot ulcer problems, have you felt: i)worried about getting ulcers in the future j)worried about being a burden on others k)that you have no control over your life l)angry that this has happened to you Not at all Quite a bit Slightly Moderately Extremely m) alone n)frustrated because you have difficulty in getting about o)frightened about the future p)badly about your-self because you can no longer work or be productive q)hopeless; that things will never get better

7 5.Because of your foot ulcer problems, how often: a)have you done things that you knew were not good for you such as eating, drinking or smoking too much b)did you disregard medical advice about how to care for your ulcer None little Some Most ll of the

8 6.Because of your foot ulcer problems, how much : a)strain has there been on your relationship with your spou-se or partner b)strain has there been on your relationship with other fa-mily members c)did you argue with your spou-se or partner d)have you felt that you are a burden on your family e)have you felt that there has been a decline in your sexual relations Not applicable/ no spouse/ no family None little Some Quite a bit great deal

9 7.Because of your foot ulcer problems, how much have you felt: a)guilty because your friends have to change plans to fit in with your limitations b)that your circle of friends is getting smaller c)that there are restrictions on the kinds of things you do with your friends Not at all little bit Moderately Quite a bit great deal d)hindered in your social life e)that you are a burden on your friends

10 8.Because of your foot ulcer problems, how much were you bothered by: a)having to keep the weight off your foot ulcer b)the amount of involved in caring for your foot ulcer (including dressing changes, waiting for the district nurse and keeping the ulcer clean) c)the appearance, odour or leaking of your ulcer d)having to depend on others to help you care for your foot ulcer Not at all little bit Moder-a tely Quite a bit Extreme-l y

11 9.How satisfied have you been with your medical care for your foot ulcer problems? Not at all little bit Moderately Quite a bit Extremely 10.Because of your foot ulcer problems: a)have you been taking better care of your feet? b)have you been taking better care of yourself in general? c)have you felt closer to your spouse or partner? d)have you had a greater appreciation of your friends? Not at all little bit Moderately Quite a bit great deal e)have you felt happier?

12 11.Because of your foot ulcer problems how much money have you spent out of your own pocket on things such as shoes, taxis, higher phone bills and home modification? None little bit Some Quite a bit great deal 12.Because of your foot ulcer problems how bothered have you been by the money you have spent out of your own pocket on things such as shoes, taxis, higher phone bills and home modification? Not at all little bit Moderately Quite a bit Extremely

13 13a.Work: re you at present in paid employment? Yes (includes being on sick leave), 1 I usually work hours per week No, I am self employed 2 No, I am unemployed 3 No, I am disabled 4 No, I am retired 5 No, describe nswer the following question only if you answered 'yes' to question 13a. 13b.Were you able to work on any day during the past two weeks? No, I have not worked since / / (day/month/year) Yes, In the past two weeks I have missed hours* from work in total hours* from work because of my foot ulcer (including to go and see the doctor) * If you haven t missed any hours, write 0' (zero) 6 1 2

14 If you are currently working either full or part, please answer the following question. 14.Because of your foot ulcer problems. a)have you found it difficult to concentrate on your job? b)have you lost from work because you were feeling unwell or have had to attend to your foot? c)have you lost job opportunities or salary? d)have you been less productive at work? None little Some Most ll of the THNK YOU FOR COMPLETING THE QUESTIONNIRE