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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1558_Библиотеки_им_академика_М_И_Перельмана
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Appendix
22
A.K. Macmillan, A.E.H. Merrie
BOWEL CONTROL QUESTIONNAIRE
The first section relates to general information, and will help with our data analysis.
1. What is your gender? (Please tick one) Female
Male
2. What is your age in years?
3. Which of these ethnic groups do you identify with most? (Please tick the box or boxes that apply to you)
NZ European
Maori
Samoan
Tongan
Cook Island Maori
Niuean
Chinese
Indian
Other
(such as Tokelauan, Japanese)
Please state:
Go to next page
Chapter 2 Epidemiology of Faecal Incontinence
23
4. What is your highest level of education? (Please tick one)
No formal qualification
School Certificate
University Entrance (e.g. Bursary)
Trade/Professional Diploma of Certificate
Bachelor’s Degree
Postgraduate Degree
5. What is your occupation?
(e.g. primary school teacher, homemaker/caregiver, motel manager, clothing machinist)
If retired or currently unemployed, please also state most recent occupation
Go to next page
24
A.K. Macmillan, A.E.H. Merrie
The following questions relate to your usual bowel habit in the last 3 months.
6. On average, how often did you pass a bowel motion in the past
3 months?
(Please tick one)
More than 3 times per day
2 to 3 times per day
Once per day
2 to 3 times per week
Once per week
Less than once per week
7. What has been the usual consistency of your bowel motions in the past 3 months?
(Please circle the ONE type that applies to you USUALLY)
Go to next page
Type Description
1 Separate hard lumps like nuts (difficult to pass)
2 Sausage shaped but lumpy
3 Like a sausage but with cracks on its surface
4 Like a sausage or snake, smooth and soft
5 Soft blobs with clear-cut edges (passed easily)
6 Fluffy pieces with ragged edges, a mushy stool
7 Water, no solid pieces, ENTIRELY LIQUID
Chapter 2 Epidemiology of Faecal Incontinence
25
The next question relates to any difficulty you may have had passing a bowel motion
in the past
3 months.
8. In the past
3 months have you experienced any of the following? (Please tick all that apply to you)
Straining on more than 1 out every 4 bowel motions
Feeling that your bowel motion is incomplete more than a
quarter of the time
Feeling of blockage during bowel motions more than a
quarter of the time
Need to use fingers or hands to help with passing a bowel
motion more than a quarter of the time
None of the above statements apply to me
9. In the past 3 months have you used medications regularly, including laxatives or antidiarrhoeal
medication, to help you pass a bowel motion?
Yes
No
Go to next page
26
A.K. Macmillan, A.E.H. Merrie
Go to next page
The following section relates to any amount of bowel leakage (accidental loss of gas, mucus or stool/faeces)
you may have had in the last month.
10. For each of the following, please mark on average how often in the past month
you experienced
any amount of bowel leakage
.
(Ngati Whatua translations are given in brackets)
PLEASE TICK ONE BOX IN EACH ROW
Never 1 to 3 Once a 2 or Once a 2 or
times week more day more
a times times
month a week a day
A. LEAKAGE OF
GAS
(tete)
B. LEAKAGE OF
MUCUS
(para tutae)
C. LEAKAGE OF
LIQUID STOOL
(tikotiko)
D. LEAKAGE OF
SOLID STOOL
(puru tutae)
11. How often in the past month did you wear a pad because of bowel leakage?
2 or more times a day
Once a day
2 or more times a week
Once a week
1 to 3 times a month
Never
Chapter 2 Epidemiology of Faecal Incontinence
27
12. In the past month, did you have any warning or feeling when you needed to pass a bowel motion?
Yes
No (Go to question 13)
If Yes, did you have to rush/hurry to reach the toilet as soon as you felt the need to pass a bowel motion?
Yes
No
13. In the past month, did you ever have bowel leakage shortly after emptying your bowels or passing a
bowel motion?
Yes
No
The following question relates to your bladder control in the past month.
14. In the past month
have you experienced loss of control of your bladder
(a) on coughing, laughing, sneezing or other physical activity?
Yes
No
(b) when feeling an urgent need to pass water (urinate), but not making it to the toilet in time?
Yes
No
Go to next page
28
A.K. Macmillan, A.E.H. Merrie
Go to next page
The next questions are only for women. If you are male Go to Question
22 on the next
page.
15. How many children have you given birth to?
If you have had no children Go to Question 21.
16. Thinking back on these births, how many were vaginal deliveries?
17. In your longest labour, how long did you push for (second stage)? (Please tick one)
Less than 1 hour
1 to 2 hours
More than 2 hours
18. Thinking back on all your labours, were forceps or instruments ever used?
Yes
No
19. Thinking back on all your labours, did you ever have a tear or episiotomy involving the muscles
of your anus (back passage)?
Yes
No
20. Thinking back on all your labours, what was the weight of your largest baby?
kg OR lbs
21. Have you ever had a hysterectomy (operation to remove your womb)?
Yes
No
If yes, was it............. Vaginal
Abdominal
Chapter 2 Epidemiology of Faecal Incontinence
29
Go to next page
The following questions are for everyone.
22. Have you ever had any of the following types of surgery to your bowels or anus
(back passage)? (Please tick all that apply to you)
Removal and rejoining of party of your bowel
Anal fistula surgery
Operation on anal muscles
Operation for haemorrhoids or piles
Major prostate operation
None of the above
23. Do you have a stoma (bag) for emptying your bowels?
Yes
No
24. Have you ever injured your anus (back passage), not including during labour?
Yes
No
25. Do you suffer from any of the following medical problems? (Please tick all that apply to you)
Inflammatory bowel disease
(Eg Crohn’s disease or ulcerative colitis)
Irritable bowel syndrome
Rectal prolapse
Diabetes
Stroke
Other neurological condition
Decreased mobility
None of the above apply
30
A.K. Macmillan, A.E.H. Merrie
Go to next page
The following section relates to how your bowel habit may be affecting your lifestyle.
26. In general, would you say your health is:
Excellent
Very Good
Good
Fair
Poor
27. For each of the items below, please indicate by circling the appropriate number, how much of the time
the item is a concern for you due to any accidental bowel leakage
(gas, liquid, solid or mucus). If it is a
concern for you for another reason (not accidental bowel leakage), then please circle “None of the time”.
PLEASE CIRCLE ONE NUMBER IN EACH ROW
Most Some A little None Not
of the of the of the of the Applicable
Because of accidental bowel leakage:
time time time time
I am afraid to go out 123 4N/A
I avoid visiting my friends 123 4N/A
I avoid staying overnight away from home 123 4N/A
It is difficult for me to get out and do things 123 4N/A
like going to a movie or to church
I cut down on how much I eat before I go out 123 4N/A
Whenever I am away from home, I try and 123 4N/A
stay near a toilet as much as possible
It is important to plan my daily activities 123 4N/A
around my bowel habit
I avoid travelling 123 4N/A
I worry about not being able to get to the 123 4N/A
toilet in time
I feel I have no control over my bowels 123 4N/A
I can’t hold on to my bowel motion long 123 4N/A
enough to get to the bathroom
I try to prevent bowel accidents by staying 123 4N/A
very near a bathroom
Chapter 2 Epidemiology of Faecal Incontinence
31
Go to next page
28. Because of any accidental bowel leakage
, please indicate, by circling one number in each row, how much
you agree or disagree with each of the following statements.
If it is a concern for you for another reason, or not a concern at all, please circle N/A.
PLEASE CIRCLE ONE ANSWER IN EACH ROW
Due to accidental bowel
Strongly Somewhat Somewhat Strongly Not
leakage:
agree agree disagree disagree Applicable
I feel ashamed 123 4N/A
I cannot do many things I want to do 123 4N/A
I worry about bowel accidents 123 4N/A
I feel depressed 123 4N/A
I worry about the smell 123 4N/A
I feel unhealthy 123 4N/A
I enjoy life less 123 4N/A
I have sex less often than I would like 123 4N/A
I feel different from other people 123 4N/A
The possibility of bowel 123 4N/A
accidents is always on my mind
I enjoy life less 123 4N/A
I am afraid to have sex 123 4N/A
I avoid travelling by plane or 123 4N/A
public transport
I avoid going out to eat 123 4N/A
Whenever I go somewhere new,
I make sure I know where the 123 4N/A
toilets are
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