Microsoft word - final npcr-enkät 2013_eng_ june 2013.doc

Patient number:
Time point:
Please fill in the date the questionnaire was completed: (Year-Month-Day):
Personal Identification Number (Year-Month-Day-Control number)
0000-00-00-0000 Please answer the questions by marking the appropriate level with
how you experienced your
symptoms during the last month.
Some questions may be answered with multiple
Questions regarding information/participation

1. Did the doctor explain the risks and benefits with the treatment/examination in a way that you understood? 2. Did the information you received before the treatment/examination harmonize with how you felt 3. Did you feel that you participated in decisions regarding your care and treatment, as much as you wanted to?
During your current disease course or treatment, how much information have you received on:

6. The possible side-effects of your treatment? 7. The expected effects of the treatment on disease 8. The effects of the treatment on sexual activity?
General questions regarding your health
9. How would you rate your
Very poor £ £ £ £ £ £ £ 11. How much does your prostate cancer disease or its 12. Are you worried because of your prostate cancer Questions regarding the urinary tract
13. Do you have problems from the urinary tract? 15. Do you have frequent urges to urinate? 16. How much do your urinary problems affect your £ I do not leak urine £ At least once a month £ At least once a week £ At least 3 times per week £ At least once a day £ At least twice a day 20. On which occasion(s) do you have urinary £ When coughing, sneezing and/or laughing £ When lifting heavy objects £ When changing position (lying-sitting, sitting- £ When going for walks £ When feeling an urge to urinate £ I leak urine without any exertion 21. How many pads do you use per 24 hours because £ About 1 per 24 hours £ About 2 per 24 hours 22. If you use pads: what type/size of pads do you use £ Attends 1 (40ml) £ Attends 2 (60ml) £ Tena 1 (100ml) £ Tena 2 (160ml) £ Molimed protect (200ml) £ Abriman Slipguard (300ml) 23. If you were to spend the rest of your life with your urinary function the way it is now, how would £ It would bother me a moderate amount £ It would bother me a lot Questions regarding bowel function
24. Do you have any problems with your stools? 25. Do you have to rush to the toilet because you have 29. How much do your bowel problems affect your £ I do not leak stools £ At least once a month £ At least once a week £ At least 3 times per week £ At least once a day £ At least twice a day 32. How many pads do you use per 24 hours because £ About 1 per 24 hours £ About 2 per 24 hours £ About 3-4 per 24 hours £ About 5 or more per 24 hours 33. On which occasion(s) do you have leakage of £ When coughing, sneezing and/or laughing £ When lifting heavy objects £ When changing position (lying-sitting, sitting- £ When passing gas £ When going for walks £ When feeling an urge to pass stools £ I leak stools without any exertion 34. If you use pads: what type of pads do you use £ Tena for men £ Sanisoft (carbon filter) 35. If you were to spend the rest of your life with your £ It would not bother me at all bowel function the way it is now, how would you £ It would bother me a moderate amount £ It would bother me a lot
Questions about sex life
36. Do you have a partner?
37. Do you have any problem with your sex life? £ Yes, continue to question 40a £ No
39. If you are not sexually active, how come? Please answer the question, and then continue to question 43
£ My partner has little or no sexual desire 40a.Have you used any potency aids during sexual £ Yes, Injection/syringe treatment (e.g. Caverject) £ Yes, An applicator with a medicated pellet that is inserted into the urethra (e.g. Bondil) £ Yes, Pill (e.g. Viagra, Cialis, Levitra) £ Yes, Other
40b If Yes, how often?
£ Sometimes £ Oftentimes £ Always 41. When was the last time you were sexually active? £ Last month £ Last six months £ Last 12 months £ Not during the last 12 months Occasionally Fewer than About half More than half of the of the time half of the almost always 43. If you were to spend the rest of your life with your £ It would not bother me at all sexual function the way it is now, how would you £ It would bother me a moderate amount the alternative that best describes your situation as it is WITHOUT any potency aids.
Mark only one answer for each question. 44. During the last 6 months, how do you rate your confidence that you could get and keep an erection? 45. During the last 6 months, No sexual Almost when you attempted sexual intercourse, how
THIS FORM IS ONLY FILLED IN IF YOU HAVE RESPONDED THAT YOU USE POTENCYAIDS.
Mark only one answer for each question.
49. During the last 6 months, how do you rate your confidence that you could get and keep an erection? 50. During the last 6 months, No sexual Almost when you attempted sexual intercourse, how THANK YOU FOR YOUR PARTICIPATION!

Source: http://npcr.se/wp-content/uploads/2013/10/FINAL-NPCR-enk%C3%A4t-2013_ENG_-June-2013.pdf