Preoperative Survey
Please complete the survey below.
Thank you!
Which of the following race/ethnic groups do you White and not Hispanic
consider yourself belonging to? African American, Black, or Brown and not Hispanic Hispanic
Other
What is your marital status? Never Married
Married
Separated or Divorced Widowed
What educational level have you completed? Eighth grade or less
Junior high school (9th grade)
Partial high school (10th or 11th grade, including trade school)
High school graduate (including trade school) Partial college (at least one year) or specialized training
Graduate of 2 or 4 year college or specialized training
Graduate degree How many total surgeries have you had in the past? 0
1 2 3 4 5 6 7 8 9 10 How many abdominal and/or pelvic surgeries have you 0
had in the past? 1
2 3 4 5 6 7 8 9 10
Which of the following medical conditions do you have Prior heart attack
(choose all that apply)? Congestive heart failure (requiring medications
like digoxin, or water pill for fluid in the lungs) Peripheral vascular disease (including ache, cramp, numbness or fatigue in the calf muscles with activity, previous artery bypass, thoracic or abdominal aneurysm)
Cerebrovascular disease including stroke or TIA (transient ischemic attack)
Dementia
Chronic pulmonary disease (including asthma or emphysema causing shortness of breath at rest or with activity)
Connective tissue disorder (including SLE [lupus], polymyositis, mixed connective tissue disease, scleroderma, polymyalgia rheumatica, and rheumatoid arthritis)
Peptic ulcer disease
Mild liver disease (including early cirrhosis or chronic hepatitis)
Diabetes (requiring treatment with insulin or oral hypoglycemic agents like metformin)
Hemiplegia (including one sided paralysis or paralysis of both legs)
Moderate or severe kidney disease (including dialysis or prior kidney transplant)
Diabetes with kidney or eye involvement
Any solid tumor without metastasis treated in the last five years (including breast, colon, lung, etc.)
Leukemia (including acute and chronic myelogenous leukemia, acute and chronic lymphocytic leukemia, and polycythemia vera)
Lymphoma (including Hodgkin's, lymphosarcoma, Waldenstrom's macroglobulinemia, myeloma, and others)
Moderate or severe liver disease
Metastatic solid tumors (including breast, lung, colon, etc.)
HIV Do you take narcotic medication (such as oxycodone, Yes hydrocodone, methadone, oxycontin, fentanyl, No morphine, etc) on a daily basis for chronic pain?
Please rate the amount of pelvic pain you typically experienced on a daily basis over the previous six
months. no pain moderate pain worst pain
(Place a mark on the scale above)
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During a typical 7-day period (a week), how many
times on average do you perform STRENUOUS EXERCISE __________________________________
(HEART BEATS RAPIDLY) for more than 15 minutes during your free time. (eg. running, jogging, hockey, football, soccer, squash, basketball, cross country skiing, judo, roller skating, vigorous swimming, vigorous long distance bicycling) During a typical 7-day period (a week), how many
times on average do you perform MODERATE EXERCISE __________________________________
(NOT EXHAUSTING) for more than 15 minutes during your free time. (e.g. fast walking, baseball,
tennis, easy bicycling, volleyball, badminton, easy swimming, alpine skiing, popular and folk dancing) During a typical 7-day period (a week), how many
times on average do you perform MILD EXERCISE __________________________________
(MINIMAL EFFORT) for more than 15 minutes during your free time. (e.g. yoga, archery, fishing from river bank, bowling, horseshoes, golf,
snow-mobiling, easy walking)
During a typical 7-day period (a week), in your Often leisure time, how often do you engage in any regular Sometimes activity long enough to work up a sweat (heart Never/rarely beating rapidly)?
My recovery time from surgery will be longer than 6
weeks Not likely Definitely likely
(Place a mark on the scale above)
My recovery expectations are based on personal experience
information from friends/family information from the internet
information from primary care physician (family practice, internal medicine)
information from ob/gyn
information from other surgeon (urogynecology, urology, colorectal)
information from other healthcare provider (medical assistant, physical therapist, nurse practicitioner, nurse)
How much bodily pain have you had in the past 4 weeks?
During the past 4 weeks, how much did pain
o None o Very Mild o Mild o Moderate o Severe o Very Severe
o Not at all
Each item below is a belief statement about your pelvic organ prolapse with which you may agree or disagree. Beside each statement is a scale which ranges from strongly disagree to strongly agree. For each item we would like you to choose the number that represents the extent to which you agree or disagree with that statement.. The more you disagree with a statement, the lower will be the number you choose. Please make sure you answer EVERY ITEM and that you choose ONLY ONE number per item. This is a measure of your personal beliefs; obviously, there are no right or wrong answers.
Strongly disagree
Moderately disagree
Slightly disagree
Slightly agree Moderately agree
Strongly agree If my prolapse worsens, it is my
own behavior which determines how soon I will feel better again As to my prolapse, what will be will be
If I see my doctor regularly, I am less likely to have problems with my prolapse
Most things that affect my prolapse happen to me by chance
Whenever my prolapse worsens, I should consult a medically trained professional
I am directly responsible for my prolapse getting better or worse Other people play a big role in whether my prolapse improves, stays the same, or gets worse Whatever goes wrong with my prolapse is my own fault
Luck plays a big part in how my prolapse improves
In order for my prolapse to improve, it is up to other people to see that the right things happen
Whatever improvement occurs with my prolapse is largely a matter of good fortune
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Following doctor's orders to the letter is the best way to keep my prolapse from getting any worse
If my prolapse worsens, it's a matter of fate
If I am lucky, my prolapse will get better
If my prolapse takes a turn for the worse, it is because I have not been taking proper care of myself
The type of help I receive from other people determines how soon my prolapse improves
People can have different feelings and thoughts about their illness. Answer the following statements as they apply to you. Check one of each of these choices depending on if you strongly agree, agree, neither agree nor disagree, disagree, or strongly disagree with the statement. Please answer EVERY QUESTION and choose ONLY ONE answer for each question.
Strongly agree Agree Neither agree nor disagree
Disagree Strongly disagree I am not sure how I would cope
with being well
When people tell me I look well it makes me feel they don't
understand
Being ill is part of my life I have made illness part of my lifeI am scared of taking treatment There are some advantages to being ill
Illness is something that I have gotten used to
People do not expect me to get better
I cannot imagine being well No one takes my illness as seriously as I would like them to take it
I wish that people would pay me more attention when I am ill
People give me more attention when I am ill
I fear returning to my usual roles when well
My life revolves around being ill It has been difficult to find treatment that is helpful to me I have problems following treatment advice
Please choose the most appropriate answer corresponding to the extent of agreement or disagreement with each statement below. Please be as honest as you can. There are no right or wrong answers. Use your judgement about your own feelings rather than how you think
"most people would answer."
Strongly disagree
Disagree Neither agree nor disagree
Agree Strongly agree In uncertain times, I usually
expect the best
It's easy for me to relax If something can go wrong for me it will
I am always optimistic about my future
I enjoy my friends a lot It is important for me to keep busy
I hardly ever expect things to go my way
I don't get upset too easily I rarely count on good things happening to me
Overall, I expect more good things to happen to me than bad
Page 7 Not at all true Hardly true Moderately true Exactly true I can always manage to solve
difficult problems if I try hard enough
If someone opposes me, I can find the means and ways to get what I want
It is easy for me to stick to my aims and accomplish my goals I am confident that I could deal efficiently with unexpected events
Thanks to my resourcefulness, I know how to handle unforeseen situations
I can solve most problems if I invest the necessary effort I can remain calm when facing difficulties because I can rely on my coping abilities
When I am confronted with a problem, I can usually find several solutions
If I am in trouble, I can usually think of a solution
I can usually handle whatever comes my way
Please respond to each item by making one selection. In the past 7 days...
Not at all A little bit Somewhat Quite a bit Very much I am satisfied with my ability to
do things for my family I am satisfied with how much work I can do (include work at home)
I feel good about my ability to do things for my family
I am satisfied with my ability to do the work that is really
important to me (include work at home)
I am satisfied with the amount of time I spend doing work (include work at home)
I am happy with how much I do for my family
I am satisfied with my ability to work (include work at home) The quality of my work is as good as I want it to be (include work at home)
I am satisfied with the amount of time I spend performing my daily routines
I am satisfied with my ability to do household chores/tasks I am satisfied with my ability to do regular personal and
household responsibilities I am satisfied with my ability to perform my daily routine I am satisfied with my ability to meet the needs of those who depend on me
I am satisfied with my ability to run errands
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People sometimes look to others for companionship, assistance, or other types of support.
How often is each of the following kinds of support available to you if you need it? Choose one number from each line.
None of the time A little of the time
Some of the time Most of the time All of the time Someone you can count on to
listen to you when you need to talk?
Someone to give you information to help you understand a situation?
Someone to give you good advice about a crisis?
Someone to confide in or talk to about yourself or your problems?
Someone whose advice you really want?
Someone to share your most private worries and fears with?
Someone to turn to for
suggestions about how to deal with a personal problem?
Someone who understands your problems?
Someone to help you if you were confined to bed?
Someone to take you to the doctor if you needed it?
Someone to prepare your meals if you were unable to do it yourself?
Someone to help with daily chores if you were sick?
Someone who shows you love and affection?
Someone to love and make you feel wanted?
Someone who hugs you?
Someone to have a good time with?
Someone to get together with for relaxation?
Someone to do something enjoyable with?
Someone to do things with to help you get your mind off things?
Are you presently employed full or part time Yes No
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The next set of questions provides us insight into how you feel about your job. Please mark the response category for each question that comes closest to reflecting your opinion about it.
Disagree very much
Disagree moderately
Disagree slightly
Agree slightly Agree moderately
Agree very much I feel I am being paid a fair
amount for the work I do.
There is really too little chance for promotion on my job.
My supervisor is quite
competent in doing his/her job.
I am not satisfied with the benefits I receive.
When I do a good job, I receive the recognition for it that I should receive.
Many of our rules and
procedures make doing a good job difficult.
I like the people I work with.
I sometimes feel my job is meaningless.
Communications seem good within this organization.
Raises are too few and far between.
Those who do well on the job stand a fair chance of being promoted.
My supervisor is unfair to me.
The benefits we receive are as good as most other
organizations offer.
I do not feel that the work I do is appreciated.
My efforts to do a good job are seldom blocked by red tape.
I find I have to work harder at my job because of the
incompetence of people I work with.
I like doing the things I do at work.
The goals of this organization are not clear to me.
I feel unappreciated by the organization when I think about what they pay me.
People get ahead as fast as they do in other places.
My supervisor shows too little interest in the feelings of subordinates.
The benefit package we have is equitable.
There are few rewards for those who work here.
I have too much to do at work.
I enjoy my coworkers.
I often feel that I do not know what is going on with the organization.
I feel a sense of pride in doing my job.
I feel satisfied with my chances for salary increases.
There are benefits we do not have which we should have.
I like my supervisor.
I have too much paperwork.
I don't feel my efforts are rewarded the way they should be.I am satisfied with my chances for promotion.
There is too much bickering and fighting at work.
My job is enjoyable.
Work assignments are not fully explained.
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The following questions are about how you feel and behave as a member of your particular profession. Please indicate how well the following statements correspond to your own attitudes and/or behavior.
Very Well Well Neutral Poorly Very Poorly
I systematically read the professional journals.
Other professions are actually more vital to society than mine.
A person who violates
professional standards should be judged by his professional peers.
A person enters this profession because he likes the work.
I make my own decisions in regard to what is to be done in my work.
I regularly attend professional meetings at the local level I think that my profession, more than any other, is essential for society.
My fellow professionals have a pretty good idea about each other's competence.
People in this profession have a real "calling" for their work.
It is easier when someone else takes responsibility for decision making.
I enjoy seeing my colleagues because of the ideas that are exchanged.
The importance of my profession is sometimes over stressed.
There really aren't any penalties for the person who violates professional standards.
The dedication of people in this field is most gratifying.
I don't have much opportunity to exercise my own judgement.
I believe that the professional organization(s) should be supported.
Some other occupations are actually more important to society than is mine.
A problem in this profession is that no one really knows what his colleagues are doing.
Professional training itself helps assure that people maintain their high ideals.
I know that my own judgment on a matter is the final judgement.
The most stimulating periods are those spent with colleagues.
Not enough people realize the importance of this profession for society.
A basic problem for the profession is the intrusion of standards other than those which are truly professional.
It is encouraging to see the high level of idealism which is maintained by people in this field.
The fact that someone checks your decisions makes this work easier.
The professional organization doesn't really do too much for the average member.
More occupations should strive to make a real contribution to society the way my own does.
Violators of professional standards face fairly severe penalties.
Although many people talk
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The real test of how good a person is in his field is the layman's opinion of him.
Any weakening of the profession would be harmful for society.
We really have no way of judging each other's competence.
It is hard to get people to be enthusiastic about their work in this field.
There is little autonomy in this work.
Although I would like to, I really don't read the journals too often.
The benefits this profession gives to individuals and society are underestimated.
The professional organization is really powerless in terms of enforcing rules.
Most people would stay in the profession even if their incomes were reduced.
My own decisions are subject to review.
Most of my own friends are not fellow professionals.
It is impossible to say that any occupation is more important than any other.
There is not much opportunity to judge how another person does his work.
Most of the real rewards of my work can't be seen by an outsider.
I am my own boss in almost every work-related situation.
The profession doesn't really encourage continued training.
If ever an occupation is indispensable, it is this one.
My colleagues pretty well know how well we all do in our work.
There are very few people who don't really believe in their work.
Most of my decisions are reviewed by other people.
Are you currently a mom to children under the age of Yes
18 No
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Please rate the extent to which you agree or disagree with each of the following statements about raising your children under the age of 18
Strongly Disagree
Disagree Somewhat Disagree
Somewhat Agree
Agree Strongly Agree The problems of taking care of a
child are easy to solve once you know how your actions affect your child, an understanding I have acquired.
Even though being a parent could be rewarding, I am frustrated now while my child is at his / her present age.
I go to bed the same way I wake up in the morning, feeling I have not accomplished a whole lot.
I do not know why it is, but sometimes when I'm supposed to be in control, I feel more like the one being manipulated.
My mother was better prepared to be a good mother than I am.
I would make a fine model for a new mother to follow in order to learn what she would need to know in order to be a good parent.
Being a parent is manageable, and any problems are easily solved.
A difficult problem in being a parent is not knowing whether you're doing a good job or a bad one.
Sometimes I feel like I'm not getting anything done.
I meet my own personal expectations for expertise in caring for my child.
If anyone can find the answer to what is troubling my child, I am the one.
My talents and interests are in other areas, not being a parent.
Considering how long I've been a mother, I feel thoroughly familiar with this role.
If being a mother of a child were only more interesting, I would be motivated to do a better job as a parent.
I honestly believe I have all the skills necessary to be a good mother to my child.
Being a parent makes me tense and anxious.
Being a good mother is a reward in itself.
Are you presently in a committed relationship? Yes No
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Answer the following questions as they apply to the quality of your relationship.
Never Rarely Often Very often
My partner keeps casting up mistakes which I made in the past.
My partner caresses me during foreplay so that I get sexually excited.
I notice that my partner finds me physically attractive.
When we are alone together my partner feels happy.
Before going to sleep we kiss and cuddle each other.
My partner makes a row about nothing just out of spite.
I think that my partner tells me frankly about his/her thoughts and feelings.
When we quarrel my partner showers me with insults.
My partner reacts positively to my sexual approaches.
We make plans for the future together.
When my partner tells me about his/her work he/she likes to know my opinions.
We make plans for the weekend together.
My partner caresses my gently and I find it very pleasant.
My partner gives me sincere compliments on my appearance.
My partner discusses matters concerning his/her working life with me.
My partner is attentive to my needs and wishes and acts accordingly.
My partner criticises me in a sarcastic way.
My partner expresses disapproval of my opinions.
When my partner has obviously treated me wrongly he/she apologises.
Usually, we stay together in the evenings for at least half an hour.
When we quarrel we can never end the quarrel.
My partner blames me when something goes wrong.
My partner puts his/her arms round me.
During a quarrel my partner shouts at me.
In the evenings my partner asks me how things have gone for me during the day.
When we quarrel my partner turns round what I say so as to mean the opposite.
My partner tells me about his/her sexual wishes.
My partner caresses me tenderly My partner tells me that he/she loves me.
My partner limits my personal freedom.
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The following questions are regarding your beliefs about gender roles. Please indicate the selection that best represents your opinion.
Strongly agree
Moderately agree
Slightly agree
Undecided Slightly disagree
Moderately disagree
Strongly disagree It is disrespectful to swear in the
presence of a lady.
The initiative in courtship should usually come from the man.
Women should have as much sexual freedom as men.
Women with children should not work outside the home if they don't have to financially.
The husband should be regarded as the legal representative of the family group in all matters of law.
Except perhaps in very special circumstances, a man should never allow a woman to pay the taxi, buy the tickets, or pay the check.
Men should continue to show courtesies to women such as holding open the door or helping them on with their coats.
It is ridiculous for a woman to run a train and a man to sew clothes.
Women should be concerned with their duties of childbearing and housetending, rather than with the desires for professional and business careers.
Swearing and obscenity is more repulsive in the speech of a woman than a man.
Are you presently a caregiver of a relative in need? Yes No
I would like to talk about some feelings you may be having as a caregiver to (mother, spouse, father, sick child(ren), etc.). Please tell me whether you
Disagree a lot Disagree a little Neither Agree a little Agree a lot I can fit in most of the things I
need to do in spite of the time it takes to care for (care-receiver)?
Taking care of (care-receiver) gives me a trapped feeling?
I get a sense of satisfaction from helping my (care-receiver)?
I feel able to handle most problems in care of (care-receiver)?
I am pretty good at figuring out what (care-receiver) needs?
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I would like to talk about some feelings you may be having as a caregiver to (mother, spouse, father, sick child(ren), etc.). Tell me how often you feel each way.
Never Rarely Sometimes Quite Frequently Nearly Always How often do you feel that your
health has suffered because of the care you must give
(care-receiver)?
How often do you feel that because of the time you spend with (care-receiver) you don't have enough time for yourself?
How often do you feel that your social life has suffered because you are caring for
(care-receiver)?
How often do you feel very tired as a result of caring for
(care-receiver)?
How often do you feel you will be unable to care for (care-receiver) much longer?
How often do you feel isolated and alone as a result of caring for (care-receiver)?
How often do you feel that you have lost control of your life because of caring for
(care-receiver)?
How often do you feel that helping (care-receiver) has made you feel closer to him/her?
How often do you feel that you really enjoy being with
(care-receiver)?
How often do you feel that taking responsibility for
(care-receiver) gives a boost to your self-esteem?
How often do you feel that (care-receiver's) pleasure over some little thing gives you pleasure?
How often do you feel that caring for (care-receiver) gives more meaning to your life?
How often do you feel reassured knowing that as long as you are helping (care-receiver), she/he is getting proper care?
How often do you feel uncertain about what to do about
(care-receiver)?
How often do you feel that you should be doing more for (care-receiver)?
How often do you feel that you could do a better job in caring for (care-receiver)?
How often do you feel that (care-receiver) is too demanding?
How often do you feel that nothing you can do seems to please (care-receiver)?
How often do you feel that (care-receiver) shows real appreciation of what you do for him/her?
How often do you feel that caring for (care-receiver) does not allow you as much privacy as you would like?
How often do you feel uncomfortable about having friends over because of (care-receiver)?
How often do you feel that caring for (care-receiver) has interfered with the use of space in your home?
