Questionário para pessoas com incontinência urinária., Esquemas de Saúde da Mulher

Baixe Questionário para pessoas com incontinência urinária. e outras Esquemas em PDF para Saúde da Mulher, somente na Docsity! Your name: Your Kaiser medical record number: 1. How would you describe your health at the present? Please tick one answer Very good Good Fair Poor Very poor 2. How much do you think your bladder problem affects your life? Please tick one answer Not at all A little Moderately A lot Please turn the page THE KING’S HEALTH QUESTIONNAIRE Below are some daily activities that can be affected by bladder problems. How much does your bladder problem affect you? We would like you to answer every question. Simply tick the box that applies to you 1 2 3 4 3. ROLE LIMITATIONS Not at all Slightly Moderately A lot A. Does your bladder problem affect your household tasks? (cleaning, shopping etc) B. Does your bladder problem affect your job, or your normal daily activities outside the home? 1 2 3 4 4. PHYSICAL/SOCIAL LIMITATION Not at all Slightly Moderately A lot A Does your bladder problem affect your physical activities (e.g. going for a walk, running, sport, gym etc)? B. Does your bladder problem affect your ability to travel? C. Does your bladder problem limit your social life? D. Does your bladder problem limit your ability to see and visit friends? 0 1 2 3 4 5. PERSONAL RELATIONSHIPS Not Not at all Slightly Moderately A lot Applicable A. Does your bladder problem affect your relationship with your partner? B. Does your bladder problem affect your sex life? C. Does your bladder problem affect your family life?