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Patient Information
1) Medical Record Number: __________________________________
2) Name: __________________________________
3) Age: __________________________________
Sample Test Questions
Please complete the survey below.
Thank you!
The following questions represent a sample of the types of questions included in this survey.
Please ask for clarification if needed.
4) Are you having surgery to remove cancer or suspected yes
cancer? no
5) If yes, what do you think the chances are that you Very unlikely
will be free of cancer in 1 year? Unlikely
About 50/50 Likely Very likely Not applicable
Estimate how likely (percentage 0-100) you think you are to have the following complication during your hospitalization. A scale is below for reference.
6) Blood clot: __________________________________
(0-100)
For the complication below, indicate the point at which the risk (percentage 0-100) would be so great that you would delay or cancel surgery. Use the same scale as above for reference.
7) __________________________________
Blood clot: (0-100)
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8) My doctor(s) should share my personal risk with me Strongly Agree
before I agree to surgery. Agree
Neither Agree nor Disagree Disagree
Strongly Disagree
Initial Survey Questions
What do you think the chances are that surgery will Very unlikely
improve your health? Unlikely
About 50/50 Likely Very likely
Are you having surgery to remove cancer or suspected yes
cancer? no
If yes, what do you think the chances are that you Very unlikely
will be free of cancer in 1 year? Unlikely
About 50/50 Likely Very likely Not applicable If yes, what do you think the chances are that you Very unlikely
will be free of cancer in 5 years? Unlikely
About 50/50 Likely Very likely Not applicable
Are you having surgery mainly to reduce pain? yes no
If yes, what do you expect your pain level will be 1 Much worse
year after surgery? Worse
About the same Better
Much better Not applicable
How well do you feel that you understand the risks of Not at all
surgery and anesthesia? Poorly
Somewhat Well Very well
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Indicate how much you agree or disagree with the following statements:
I need more information about the risks and benefits Strongly disagree
of surgery and anesthesia. Disagree
Neither agree or disagree Agree
Strongly agree It is hard for me to decide if the benefits of Strongly disagree
surgery outweigh the risks. Disagree
Neither agree or disagree Agree
Strongly agree
Risk Estimates
Please complete the survey below.
Thank you!
Estimate how likely (percentage 0-100) you think you are to have each of the following complications during your hospitalization. A scale is below for reference.
18) A SERIOUS complication: __________________________________
(Includes cardiac arrest, heart attack, pneumonia, (0-100%) kidney injury or failure, blood clot in legs or
lungs, unexpected return to operating room for further operation, infection, blood
infection/sepsis, unplanned need for a breathing tube, urinary tract infection, wound disruption)
19) ANY complication: __________________________________
(wound infection or disruption, pneumonia, unplanned (0-100%) need for a breathing tube, blood clot in legs or
lungs, unplanned need for a breathing machine > 48 hours, kidney injury or failure, urinary tract
infection, stroke, cardiac arrest, heart attack, unplanned return to the operating room for further operation, blood infection/sepsis)
20) Pneumonia: __________________________________
(0-100%)
21) A heart problem: __________________________________
(Includes heart attack or cardiac arrest) (0-100%)
22) Surgical wound infection: __________________________________
(0-100%)
23) Urinary tract infection: __________________________________
(0-100%)
24) Blood clot: __________________________________
(0-100%)
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25) Kidney failure: __________________________________
(0-100%)
26) Readmission to hospital: __________________________________
(Unplanned return to hospital after discharge because (0-100%) of complications)
27) Unplanned return to operating room for more surgery: __________________________________
(0-100%)
28) Death: __________________________________
(0-100%)
29) Discharge to a nursing or rehab facility: __________________________________
(0-100%) 30) How many days do you expect to stay in the hospital?
1 2 3 4 5 6 7 8 9 10 More than 10 days
Survey Break
Please complete the survey below.
Thank you!
You will now be shown your calculated personal risk estimates. After you have reviewed your results, you will complete the final survey that follows.
Please wait to review your calculated risks with study personnel.
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Closing Questions
Before participating in this study, I had already yes seen the calculator's estimates of my personal risk no
Indicate how much you agree or disagree with the following statements:
Strongly Agree Agree Neither Agree nor Disagree
Disagree Strongly Disagree The calculator's estimates of my
personal risk were different than I expected based on what my doctors told me.
The calculator's estimates of my personal risk were easy to understand.
The calculator's estimates of my personal risk have helped me understand my risks better.
The calculator's estimates of my personal risk were useful to me.
My doctor(s) should share my personal risk with me before I agree to surgery.
Knowing my personal risk has made me less anxious about surgery.
Would you have wanted to know these risk estimates yes
prior to consenting for surgery? no
neutral How well do you feel that you understand the risks of Not at all
surgery and anesthesia? Poorly
Somewhat Well Very well
Would you consider using medicine, diet, physical Yes therapy, or a similar program to lower your personal Maybe
risk for surgery? No
How long would you be willing to delay your surgery I would not delay surgery
to do this? 1 month
2 months 3 months 4 months
more than 6 months 6 months