Date of questionnaire completion:
Trial ID
Immediate Management of the Patient with Ruptured aneurysm:
Open Versus Endovascular repair
QUESTIONNAIRE ON USE OF HEALTH SERVICES
BETWEEN 3 and 12 MONTHS AFTER ANEURYSM
REPAIR
We would be grateful if you would take a few minutes to answer the
following questions about services you may have used since
*
This date is either that of your previous follow up appointment or if you
did not attend for your 3 month follow up, it is 3 months after your
operation.
Section A (Questions 1-5) is about services you may have used
because of your aneurysm.
Section B (Questions 6) is about services you may have used for
other health reasons.
*local trial co-ordinator to date this page, the top of page 3 and questions 2.1, 3.1, 4.1,
4.3 and 6.1
Health Resources Questionnaire
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Trial ID
HOW TO FILL IN THE QUESTIONNAIRE
Most questions can be answered by ticking the box next to the answer
that applies to you. Please tick one box only for each question.
Example:
Since you left hospital after your aneurysm repair have you had further
hospital treatment of your aneurysm, by either a doctor or nurse?
Yes No
If yes, where was this?
Name of Hospital: e.g. West Middlesex
If yes, did you have another operation?
Yes
No Example:
How many more operations have you had?
Exact number
of operations
____ops
OR if you can’t remember the exact number of
operations tick one of the following boxes
1 or 2 3 or more
Example:
How many appointments have you had with the doctor or nurse at an
outpatient’s department because of your aneurysm?
Who?
1 A doctor
2 A nurse
How
many
times?
none
OR if you can’t remember the exact
number of times tick one of the
following boxes
1 or 2
3 or 4 5 or more
1 or 2
3 or 4
5 or more
Health Resources Questionnaire
Examples for filling in the questionnaire
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Trial ID
Services used since
<please insert relevant date above and at 3.1, 4.1, 4.3 and 6.1>
Section A: Service use for reasons related to your aneurysm
1.1 Have you had further hospital treatment of your aneurysm?
Yes
No
1.2 If yes, where was this? Name of Hospital: ____________
1.3 If yes, did you have another operation?
Yes
No
1.4 How many more operations have you had?
Exact number of
operations
____op(s)
OR if you can’t remember the exact number of
operations tick one of the following boxes
1 or 2
3 or more
1.5 How many appointments have you had with the doctor, nurse or
radiographer at an outpatients department because of your aneurysm?
How
many
times?
Who?
1 A doctor
2 A nurse
3 A radiographer
OR if you can’t remember the exact
number of times tick one of the following
boxes
1 or 2
3 or 4
5 or more
1 or 2
3 or 4
5 or more
1 or 2
3 or 4
5 or more
1.6 Have you seen your GP because of your aneurysm?
Yes
No
1.7 If yes, how many times have you seen the GP?
Exact number
of times
____time(s)
OR if you can’t remember the exact number of times
tick one of the following boxes
1 or 2
3 or 4
5 or more
Health Resources Questionnaire
Services following discharge
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Trial ID
2 District nurse visits
2.1 Has a district nurse been to visit you at home since
Yes
No
2.2 If yes, how often has the district nurse been to see you?
Several times a week
Once a week
Once a fortnight
Once a month
Other (please specify) __________________________________
2.3 For how many weeks has the district nurse been to see you?
Exact number
of weeks
___weeks
OR if you can’t remember exactly how many weeks
tick one of the following boxes
1 to 3 weeks
4 to 7 weeks
8 to 12 weeks
3 Stay in a convalescent home or nursing home
3.1 Have you stayed in either a convalescent home or nursing home
since
Yes
No
3.2 If yes, how many weeks you have stayed there?
Exact number
of weeks
____weeks
OR if you can’t remember exactly how many weeks
tick one of the following boxes
1 week or less
1 to 4 weeks
Health Resources Questionnaire
District nurse visits & Stay in a convalescent or nursing home
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4 Use of social services
4.1 Have you seen a social worker for reasons related to your aneurysm
since
?
Yes
No
4.2 If yes, how many times?
Exact number
of times
____time(s)
OR if you can’t remember the exact number of times
tick one of the following boxes
1 or 2
3 or 4
5 or more
4.3 Has a home carer (someone from social services who comes to
assist with cleaning and feeding) visited you since
Yes
No
4.4 If yes, how often have has the home carer visited you?
Once a day
1 – 2 times a week
Once a month
Other (please specify) ____________
4.5 For how many weeks have you had a home carer?
Exact number
of weeks
____weeks
OR if you can’t remember exactly how many weeks
tick one of the following boxes
1-3 weeks
4-7 weeks
8-12 weeks
4.6 Did you have a home carer before your aneurysm repair?
Yes
No
Health Resources Questionnaire
Use of social services
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5 Input from patients and carers
5.1 Have you had to leave paid employment because of your aneurysm?
Yes
No
5.2 Have you had to take time off work because of your aneurysm?
Yes
No
5.3 If yes, how many days?
Exact number
of days
_____days
OR if you can’t remember the exact number of days
tick one of the following boxes
1-5 days
6-10 days
more than 10 days
5.4 Have any of your friends or relatives had to have time off work for
reasons relating to your aneurysm?
Yes
No
5.5 If yes, how many days?
Exact number
of days
____days
OR if you can’t remember the exact number of days
tick one of the following boxes
1-5 days
5-10 days
more than 10 days
5.6 Do any of your family or friends help you with feeding, washing or
dressing?
Yes
No
5.7 If yes, on average for how many hours a day?
Exact number
of hours
____hours
OR if you can’t remember the exact number of hours
tick one of the following boxes
2 hours or less
3 to 5 hours
More than 5 hours
Health Resources Questionnaire
Input from patients and carers
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Section B: Service use for reasons not related to your aneurysm
6.1 Have you had hospital treatment by either a doctor or nurse for
anything other than your aneurysm (examples might include breathing
problems, skin rashes, constipation etc) since
?
Yes
No
6.2 If yes, where was this?
Name of Hospital:_______________________
6.3 If yes, what was the treatment for?
______________________
6.4 How many appointments have you had with the doctor or nurse at an
outpatients department for reasons unrelated to your aneurysm?
Who?
How many
times?
A doctor
A nurse
OR if you can’t remember the exact
number of times tick one of the
following boxes
1 or 2
3 or 4
5 or more
1 or 2
3 or 4
5 or more
6.5 Have you seen your GP for reasons unrelated to your aneurysm?
Yes
No
6.6 If yes, how many times have you seen the GP for reasons unrelated
to your aneurysm?
Exact number
of times
____times
OR if you can’t remember the exact number of times
tick one of the following boxes
1 or 2
3 or 4
5 or more
Many thanks for your help.
Health Resources Questionnaire
Services at 12m
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