James Paget University Hospital logo
Pre-operative breast surgery questionnaire for women aged 65
years and over
Thank you for taking the time to complete this short questionnaire.
We will use your responses to analyse and improve the quality of
care we provide for our patients
Section One: Your Perceptions
With your breast area in mind, in the past two weeks, how satisfied or dissatisfied have you
been with:
Very
dissatisfied
Somewhat
dissatisfied
Somewhat
satisfied
Very
satisfied
No
opinion
a. How you look in the mirror clothed?
b. How you look in the mirror
unclothed?
With your breast area in mind, in the past two weeks, how often have you felt:
None of
the time
A little of
the time
Some of
the time
Most of
the time
All of the
time
a. Self-confident?
b. Feminine in your clothes?
c. Normal?
In the past two weeks, on the affected side, how often have you experienced:
None of
the time
A little of
the time
Some of
the time
Most of
the time
All of the
time
a. Shoulder pain?
b. Arm pain?
c. Tenderness in your breast area?
d. Sharp pains in your breast area?
Thinking of your sexuality, how often do you generally feel:
None
of the
time
A little
of the
time
Some
of the
time
Most
of the
time
All of
the
time
No
opinion
a. Sexually attractive in your clothes?
b. Sexually attractive when unclothed?
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James Paget University Hospital NHS Foundation Trust Prejuvenate Form
January 2015
Section Two- Your general health and activity
Has your weight changed in the last year?
Yes / No
If so, was this intentional?
Yes/ No
Please indicate amount gained (_______) or lost (_________)
Regarding your energy levels, please choose from the following options:
Rarely or
none of the
time
(<1 day)
Some or a
little of the
time
(1-2 days)
Moderate
amount of
time
(3-4 days)
Most of
the time
a. I felt that everything I did was an effort
b. I could not get going
Now, thinking of your activities in the last 14 days:
On how many days did you do vigorous physical activities like heavy lifting, digging, aerobics,
or fast bicycling?
Think about only those physical activities that you did for at least 10 minutes at a time.
0-1 day
2-3 days
4-5 days
6-7 days
8-9 days
10-11 days
12-13 days
14 days
On how many days did you do moderate physical activities like carrying light loads, bicycling at
a regular pace or playing tennis?
Again, think about only those physical activities that you did for at least 10 minutes at a time.
0-1 day
2-3 days
4-5 days
6-7 days
8-9 days
10-11 days
12-13 days
14 days
On how many days did you walk for at least 10 minutes at a time?
This includes walking at home, travelling from place to place and walking for recreation.
0-1 day
2-3 days
4-5 days
6-7 days
8-9 days
10-11 days
12-13 days
14 days
Finally, how much time on average do you usually spend sitting down on a weekday?
0-1 hour
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2-3 hours
4-5 hours
6-7 hours
8-9 hours
10-11 hours
12-13 hours
James Paget University Hospital NHS Foundation Trust Prejuvenate Form
>14 hours
January 2015
Section Three: Your feelings
This final part of the questionnaire is designed to help us know how you feel. Read each item and
place a firm tick in the box opposite the reply, which comes closest to how you have been feeling
in the past week.
Tick one box only in each section
1 I feel tense or wound up:
Most of the time (3)
A lot of the time (2)
Time to time, occasionally (1)
Not at all (0)
2 I get a sort of frightened feeling as if
something awful is about to happen:
Very definitely and quite badly (3)
Yes, but not too badly (2)
A little, but it doesn’t worry me (1)
Not at all (0)




8 I still enjoy the things I used to enjoy:
Definitely as much (0)
Not quite so much (1)
Only a little (2)
Hardly at all (3)








9 I can laugh and see the funny side of
things:
As much as I always could (0)
Not quite so much now (1)
Definitely not so much now (2)
Not at all (3)




10 I feel cheerful:
Not at all (3)
Not often (2)
Sometimes (1)
Most of the time (0)




3 Worrying thoughts go through my
mind:
A great deal of the time (3)
A lot of the time (2)
From time to time but not too often (1)
Only occasionally (0)




4 I can sit at ease and feel relaxed:
Definitely (0)
Usually (1)
Not often (2)
Not at all (3)




11 I feel as if I am slowed down:
Nearly all the time (3)
Very often (2)
Sometimes (1)
Not at all (0)








12 I have lost interest in my
appearance:
Definitely (3)
I don’t take so much care as I should (2)
I may not take quite as much care (1)
I take just as much care as ever (0)




5 I get a sort of frightened feeling like
“butterflies” in the stomach:
Not at all (0)
Occasionally (1)
Quite often (2)
Very often (3)
6 I feel restless as if I have to be on the
move:
Very much indeed (3)
Quite a lot (2)
Not very much (1)
Not at all (0)
7 I get sudden feeling of panic:
Very often indeed (3)
Quite often (2)
Not very often (1)







13 I look forward with enjoyment to things:
As much as I ever did (0)

Rather less than I used to (1)

Definitely less than I used to (2)

Hardly at all (3)

14 I can enjoy a good book or radio or
TV programme:
Often (0)
Sometimes (1)
Not often (2)
Very seldom (3)




.
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James Paget University Hospital NHS Foundation Trust Prejuvenate Form
January 2015
Thanks for completing this questionnaire. Please return to your breast care nurse either in the stamped
addressed envelope provided, or at your next appointment.
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James Paget University Hospital NHS Foundation Trust Prejuvenate Form
January 2015