Postoperative Questionnaire Survey on

Endoscopic Submucosal Dissection or Laparoscoy-Assisted Colectomy

Patient number (ID):

Name:

Procedure:

□ Endoscopic submucosal dissection

□ Laparoscopy-assisted colectomy

Procedure date: MM/DD/YYYY

Questionnaire date: MM/DD/YYYY (2 weeks after the procedure)

—Notes—

Thisquestionnaire evaluates your current physical conditions following the procedure.

Results of this questionnaire would not be shared with your physician, and your privacy will be protected.

Although these might seem similar questions, please answer each one honestly and circle the score between “0” and “100.”

Once you finish the questionnaire, please ensure that there are no unattempted questions.

We will collect the questionnaireat a later date.

We appreciate your cooperation.

Endoscopy Division / Colorectal Surgery Division, National Cancer Center Hospital

Question 1. How is your general health?

Very poor Very good

Question 2. Compared with that before the procedure, how is your current health?

Much worse Same

Question 3. The following questions are on your daily activities.

Do you find these activities difficultbecause of health reasons? If so, how difficult?

a)Intense exercise, for example, running hard, lifting a heavy object, or playing intense sports.

Very difficult Not difficult at all

b)Moderate activity, for instance, cleaning the yardortaking a 1–2-hr(s) walk.

Very difficult Not difficult at all

c)Lift or carry an object that is a little heavy (e.g., a shopping bag).

Very difficult Not difficult at all

d)Climb several stairs.

Very difficult Not difficult at all

e)Climb one stair.

Very difficult Not difficult at all

f)Bend forward, kneel, or crouch.

Very difficult Not difficult at all

g)Walk 1 km or more.

Very difficult Not difficult at all

h)Walk several 100 m.

Very difficult Not difficult at all

i)Walk about100 m.

Very difficult Not difficult at all

j)Take a bath or change clothes by yourself.

Very difficult Not difficult at all

k)Get out of bed.

Very difficult Not difficult at all

Question 4. Do you have any of the following problems with work or daily activities (e.g., household chores) because of physical reasons?

a)I have reduced the time spent on work and/or daily activities.

Always Never

b)I cannot perform work and/or daily activities as much as I expected.

Always Never

c)I cannot perform some work and/or daily activities.

Always Never

d)It is difficult to perform work and/or daily activities (e.g., it takes more effort than usual).

Always Never

Question 5. Currently, how much pain do you experience?

Extreme pain No pain

Question 6. How much is your work (including household chores) affected by pain?

Very much Never

Question 7. When performing work and/or daily activities (e.g., household chores), do you have any of the following problems because of psychological reasons (e.g., feeling depressed or anxious)?

a)I have reduced the time spent on work and/or daily activities.

Always Never

b)I cannot perform work and/or daily activities as much as I expected.

Always Never

c)I cannot focus on or complete work and/or daily activities as usual.

Always Never

Question 8. How much of your relationship with family, friends, neighbors, and other peoplehas been affected by physical and/or psychological reasons?

Very much Not at all

Question 9. How often is the time you spend onvisiting friends and families affected by physical and/or psychological reasons?

Always Never

Question 10. The following questions are about your current feelings.

a)Do you feel energetic?

Never Always

b)Do you feel happy?

Never Always

c)Do you feel calm?

Never Always

Question 11. The following questions are on your feelings about the treatment.

a)Are you very nervous?

Always Never

b)Are you depressed to the point where you feel you cannot control the condition?

Always Never

c)Are you tired because of the treatment?

Always Never

Question 12. How is your current defecation status?

Extreme diarrhea Same as that before the treatment

Question 13. How is your current defecation status?

Extreme constipation Same as that before the treatment

Question 14. Does your bowel movement interfere with your daily life?

It interferes substantially Same as that before the treatment

Question 15. Do you feel bloated?

Very much Not at all

Question16. How is your current appetite?

No appetite Excellent appetite

Question17. How is your drinking status?

I never want to I drink enough water

Question 18. Please mark the score that best describes your anxiety for recurrence of the disease.

Very anxious Not at all anxious

Question19.How was the physical burden of the treatment (endoscopic treatment or laparoscopic surgery)?

Very difficult Very easy

This is the end of the questionnaire.

Thank you very much for your cooperation.

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