Appendix 1: Urolithiasis Survey
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1. Have you ever had a kidney stone (requiring a visit to a physician or surgical intervention, or that passed on its own)?
(1) No
(2) Yes
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2. How many kidney stone events (requiring an emergency room visit or surgical intervention) have you had?
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3. Did any of your kidney stone event(s) happen while you were in medical training or working in the medical field?
(1) No
(2) Yes
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4. Have you had surgery to treat a kidney stone?
(1) No
(2) Yes
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5. If you did not have surgery to treat your kidney stone(s), did the kidney stone pass spontaneously?
(1) No
(2) Yes
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6. How many times have you had surgery for kidney stones?
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7. On a scale of 0 to 10, with 0 being "Not at all stressful" and 10 being "Extremely stressful," how stressful is your job?
0 - Not at all stressful
1
2
3
4
5
6
7
8
9
10 - Extremely stressful
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8. On average, is your fluid intake less than 60 ounces (1.8 L) per day?
(1) No
(2) Yes
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9. What factors limit your fluid intake? (Mark all that apply.)
Work
Social
Health
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10. What is your average fluid intake per day? (Ounces)
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11. Considering a 7-day period (1 week), how many times on average do you get 30 minutes or more of moderate (nonexhausting) exercise, ie, fast walking, easy swimming,
alpine skiing, popular and folk dancing, tennis, easy bicycling, baseball, volleyball?
None
1
2
3
4
5
6
7
8 or more
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12. Do you work in an operating room?
(1) No
(2) Yes
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13. What role do you perform in an operating room?
(1) Physician
(2) Nurse
(3) Certified Registered Nurse Anesthetist (CRNA)
(4) Surgical Assistant
(5) Surgical Technician
(6) Other, please specify below:
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14. Are you...
(1) Staff
(2) A resident
(3) A fellow
(4) Other
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15. What is your current height?
Feet, Inches
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16. What is your current weight?
Pounds
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17. Have you ever had a bowel resection?
(1) No
(2) Yes
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18. Have you ever been diagnosed as having a neurogenic bladder?
(1) No
(2) Yes
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19. Do you have diabetes mellitus?
(1) No
(2) Yes
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20. Do you have a family history of kidney stone disease?
(1) No
(2) Yes