Domain C: Quality of life over the past 6-8 weeks as impacted by the fistula:
(1) sleep disturbed
(2) avoid getting physically close to another person
(3) restricted sexual activity
(4) restricted socialization
(5) restricted exercise or physical activities
(6) restricted travel
(7) makes me feel embarrassed or ashamed
(8) concerned that others may find out that I have a fistula
(9) restricted ability to work or study
(10) financial loss
(11) worry about finding or needing the toilet when away from home
(12) only go to places where clean toilet and washing facilities are known to exist
(13) take spare underwear and wipes when going out
(14) hard to keep self clean because of the fistula
(15) concerned about people being able to smell discharge from the fistula
(16) feel anxious, depressed, down or hopeless
(17) worry that the fistula will never be cured
(18) worry that a stoma will be needed some day
(19) worry that a temporary stoma may become permanent
where:
• Item 18 is modified if the patient already has a stoma.
• Item 19 is modified if the patient does not have a temporary stoma OR if the patient has a permanent stoma.
|
Response
|
Points
|
|
strongly disagree
|
0
|
|
disagree
|
1
|
|
unsure
|
2
|
|
agree
|
3
|
|
strongly agree
|
4
|
total score for domain C =
= SUM(points for all of the items)
Interpretation:
• minimum domain C score: 0
• maximum domain C score: 76
• The higher the score the greater the impact of the fistula on the patient's quality of life.
