REV_VaricoseVeins_12pp_Q_PostOp
29/10/09
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Varicose Veins Surgery
Questionnaire
After your operation
About three months ago you had a Varicose Veins Operation. You may
remember that you agreed that we could send you an After your operation
questionnaire. Please can you fill in this questionnaire and return it using the
provided pre-paid envelope. Thank you for your help.
Q1. Is anyone helping you fill in this questionnaire?
Yes
No
1
2
If the answer is yes, please give the relationship to you of the person
assisting you
Family member
e.g. spouse,
Other
child, parent relative
1
2
Carer
Friend/
neighbour
3
Healthcare
professional
e.g. nurse/doctor
4
5
Other
6
If you are helping to complete this questionnaire on behalf of the
patient, please ensure that the information given below is that of the
patient and not your own.
Q2. What is your date of birth?
D
D
M
M
VV2A/EN/001/
Y
Y
Y
Y
VV2A/EN
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Varicose Veins Surgery Questionnaire – After your operation
A question about your current home circumstances
Q3. Which statement best describes your living arrangements?
I live with partner/spouse/family/friends
1
I live alone
2
I live in a nursing home, hospital or other long-term care home
3
Other
4
Q4. Please confirm when your varicose veins operation took place
(day, month, year).
2
D
D
M
M
0
Y
Y
Some questions about your surgery and your health
Please mark the boxes below with a tick or numbers where appropriate.
If you are unsure about how to answer a question, please give the best
answer you can.
Q5. Did you experience any of the following problems after your
operation? Please tick Yes or No for each problem.
Yes
No
Allergy or reaction to drug
1
2
Urinary problems
1
2
Bleeding
1
2
Wound problems
1
2
Q6. Have you been readmitted to hospital since the operation
on your varicose veins?
Yes
No
1
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2
2
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VV2A/EN
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Varicose Veins Surgery Questionnaire – After your operation
Q7. Have you had another operation on your varicose veins?
Yes
No
1
2
Q8. In general, would you say your health is:
Excellent
1
Very good
2
Good
3
Fair
Poor
4
5
Q9. How would you describe the results of your operation?
Excellent
1
Very good
2
Good
3
Fair
Poor
4
5
Q10. Overall, how are the problems now with your varicose veins on
which you had surgery, compared to before your operation?
Much
better
1
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A little
better
2
VV2A/EN/001/
About the
same
3
A little
worse
4
VV2A/EN
Much
worse
5
3
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Varicose Veins Surgery Questionnaire – After your operation
The following questions relate to problems commonly associated with varicose
veins. We appreciate that you may no longer have any visible varicose veins
after your surgery but please try and answer each question as best you can.
Q11. Do you have any visible varicose veins on your legs
at the moment?
Right
(Please tick one box for each leg)
Leg
Left
Leg
Yes
1
1
No
2
2
Q12. If Yes, please draw in your varicose veins in the diagram(s) below.
If No, please proceed to Q13.
Legs viewed from front
Legs viewed from back
Right Leg
Left Leg
Left Leg
Q13. In the last two weeks, for how many days did your
varicose veins cause you pain or ache?
(Please tick one box for each leg)
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4
VV2A/EN/001/
Right Leg
Right
Leg
Left
Leg
None at all
1
1
Between 1 and 5 days
2
2
Between 6 and 10 days
3
3
For more than 10 days
4
4
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Varicose Veins Surgery Questionnaire – After your operation
Q14. During the last two weeks, on how many days did you take
painkilling tablets for your varicose veins?
(Please tick one box)
None at all
1
Between 1 and 5 days
2
Between 6 and 10 days
3
For more than 10 days
4
Q15. In the last two weeks, how much ankle swelling
have you had?
(Please tick one box)
None at all
1
Slight ankle swelling
2
Moderate ankle swelling
(e.g. causing you to sit with your feet up whenever possible)
3
Severe ankle swelling
(e.g. causing you difficulty putting on your shoes)
Q16. In the last two weeks, have you worn support
stockings or tights?
(Please tick one box for each leg)
Right
Leg
Left
Leg
No
1
1
Yes, those I bought myself without a doctor’s prescription
2
2
Yes, those my doctor prescribed for me
which I wear occasionally
3
3
Yes, those my doctor prescribed for me
which I wear every day
4
4
Q17. In the last two weeks, have you had any itching
in association with your varicose veins?
(Please tick one box for each leg)
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4
Right
Leg
Left
Leg
No
1
1
Yes, but only above the knee
2
2
Yes, but only below the knee
3
3
Both above and below the knee
4
4
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Varicose Veins Surgery Questionnaire – After your operation
Q18. Do you have purple discolouration caused by tiny
blood vessels in the skin, in association with your
varicose veins?
(Please tick one box for each leg)
Right Left
Leg Leg
No
1
1
Yes
2
2
Q19. Do you have a rash or eczema in the area
of your ankle?
(Please tick one box for each leg)
Right Left
Leg Leg
No
1
1
Yes, but it does not require any treatment from a
doctor or district nurse
2
2
Yes, and it requires treatment from my doctor or district nurse
3
3
Q20. Do you have a skin ulcer associated with your
varicose veins?
(Please tick one box for each leg)
Right Left
Leg Leg
No
1
1
Yes
2
2
No
1
Q21. Does the appearance of your varicose veins
cause you concern?
(Please
Please tick one box
box)
Yes, their appearance causes me slight concern
2
Yes, their appearance causes me moderate concern
3
Yes, their appearance causes me a great deal of concern
4
Q22. Does the appearance of your varicose veins influence
your choice of clothing including tights?
(Please
Please tick one box
box)
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6
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No
1
Occasionally
2
Often
3
Always
4
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Varicose Veins Surgery Questionnaire – After your operation
Q23. During the last two weeks, have your varicose veins interfered
with your work/housework or other daily activities?
(Please tick one box)
No
1
I have been able to work but my work has suffered
to a slight extent
2
I have been able to work but my work has suffered
to a moderate extent
3
My veins have prevented me from working one day or more
4
Q24. During the last two weeks, have your varicose veins
interfered with your leisure activities (including sport,
hobbies and social life)?
(Please tick one box)
+
No
1
Yes, my enjoyment has suffered to a slight extent
2
Yes, my enjoyment has suffered to a moderate extent
3
Yes, my veins have prevented me taking part in any leisure activities
4
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Varicose Veins Surgery Questionnaire – After your operation
By placing a tick in one box in each group (Questions 25–29) below, please
indicate which statements best describe your own health state today.
Q25. Mobility
I have no problems in walking about
1
I have some problems in walking about
2
I am confined to bed
3
Q26. Self-Care
I have no problems with self-care
1
I have some problems washing or dressing myself
2
I am unable to wash or dress myself
3
Q27. Usual Activities
(e.g. work, study, housework, family or leisure activities)
I have no problems with performing my usual activities
1
I have some problems with performing my usual activities
2
I am unable to perform my usual activities
3
Q28. Pain/Discomfort
I have no pain or discomfort
1
I have moderate pain or discomfort
2
I have extreme pain or discomfort
3
Q29. Anxiety/Depression
+
8
I am not anxious or depressed
1
I am moderately anxious or depressed
2
I am extremely anxious or depressed
3
VV2A/EN/001/
VV2A/EN
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Varicose Veins Surgery Questionnaire – After your operation
Best
imaginable
health state
Q30. To help people say how good or bad a
health state is, we have drawn a scale
(rather like a thermometer) on which the
best state you can imagine is marked
100 and the worst state you can imagine
is marked 0.
100
We would like you to indicate on this scale
how good or bad your own health is today,
in your opinion. Please do this by drawing
a line from the box below to whichever
point on the scale indicates how good or
bad your health state is today.
9•0
8•0
7• 0
6•0
Your own
health state
today
5•0
4•0
3•0
2•0
1•0
0
Worst
imaginable
health state
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VV2A/EN/001/
VV2A/EN
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Varicose Veins Surgery Questionnaire – After your operation
Q31. Today’s date (day, month, year)
2
D
D
M
M
0
Y
Y
Q32. Do you consider yourself to have a disability?
Yes
No
1
2
Thank you for your assistance.
Please return this questionnaire in the envelope provided.
You do not have to use a stamp – the postage is already paid.
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10
VV2A/EN/001/
VV2A/EN
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blank page
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Contact us for further details:
• Freephone: 0800 917 1163
• E-mail: [email protected]
• Write: PROMs Survey, PO Box 909, Aylesbury, HP22 9HT
• Website: www.nhs.uk/proms
© Crown copyright 2008. Except where expressly stated to the contrary, this questionnaire is protected by Crown copyright.
Any and all copyrights in question 5 vest in London School of Hygiene and Tropical Medicine.
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Any and all copyrights in questions 25–30, their order, layout, and images printed on page 9 vest in the EuroQol Group.
The EuroQol Group reserves all rights. © 1992 EuroQol Group. EQ-5DTM is a trademark of the EuroQol Group.
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