Diabetic Foot Ulcer Scale-Short Form

Transcription

1 Diabetic Foot Ulcer Scale-Short Form INSTRUCTIONS: These questions ask about the effect that foot ulcer problems may have on your daily life and well-being. Please read each question carefully and think about the effect of your foot ulcer problems. Answer 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. DFS-SF United Kingdom/English (original version) 1

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 organising for leisure activities Not at all A little bit Moderately Quite a bit A great deal DFS-SF United Kingdom/English (original version) 2

3 2. Because of your foot ulcer problems, how often have you felt: None A little Some Most a) fatigued or tired b) drained c) that you had difficulty sleeping d) pain while walking or standing All of the e) pain during the night DFS-SF United Kingdom/English (original version) 3

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 organising your daily life e) felt that doing anything took longer than you would have liked None A little Some Most All of the DFS-SF United Kingdom/English (original version) 4

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 things yourself c) frustrated because you were not able to do what you wanted to do d) worried that your ulcer(s) will never heal e) worried that you may have to have an amputation f) worried about injury to your feet g) depressed because you were not able to do what you wanted to do Not at all Slightly Moder -ately Quite a bit Extremely DFS-SF United Kingdom/English (original version) 5

6 4. Because of your foot ulcer problems, have you felt: h) worried about getting ulcers in the future i) angry that this has happened to you j) frustrated because you have difficulty in getting about Not at all Slightly Moder -ately Quite a bit Extremely DFS-SF United Kingdom/English (original version) 6

7 5 Because of your foot ulcer problems, how often 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 None A little of the Some Most All THANK YOU FOR COMPLETING THE QUESTIONNAIRE DFS-SF United Kingdom/English (original version) 7