Please answer the 37 questions of the health survey completely, honestly, and without interruptions with regards to how your (or your child’s) pilonidal condition is affecting you or them.
Choose one option for each questionnaire item. When you are done, click the button to “Print Completed Form” and save as a PDF or print on paper. Please complete prior to your day of surgery.
Do not refresh your browser webpage or you will lose your input data. Your information is not captured or stored by The Sternberg Clinic.
1. In general, would you say your health as affected by your pilonidal condition is:
1 – Excellent
2 – Very good
3 – Good
4 – Fair
5 – Poor
2.
Compared to one year ago
, how would you rate your health in general
now as you live with a pilonidal condition?
1 – Much better now than one year ago
2 – Somewhat better now than one year ago
3 – About the same
4 – Somewhat worse now than one year ago
5 – Much worse now than one year ago
The following items are about activities you might do during a typical day. Does
your pilonidal condition now limit you
in these activities? If so, how much?
Yes, limited a lot
Yes, limited a little
No, not limited at all
3.
Vigorous activities
, such as running, lifting heavy objects, participating in strenuous sports
1
2
3
4.
Moderate activities
, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf
1
2
3
5. Lifting or carrying groceries
1
2
3
6. Climbing
several
flights of stairs
1
2
3
7. Climbing
one
flight of stairs
1
2
3
8. Bending, kneeling, or stooping
1
2
3
9. Walking
more than a mile
1
2
3
10. Walking
several blocks
1
2
3
11. Walking
one block
1
2
3
12. Bathing or dressing yourself
1
2
3
During the
past 4 weeks
, have you had any of the following problems with your work or other regular daily activities
as a result of your pilonidal condition
?
During the
past 4 weeks
, have you had any of the following problems with your work or other regular daily activities
as a result of any emotional problems
(such as feeling depressed or anxious)?
20. During the
past 4 weeks
, to what extent has your physical health or emotional problems interfered with your normal social activities with family, friends, neighbors, or groups?
1 – Not at all
2 – Slightly
3 – Moderately
4 – Quite a bit
5 – Extremely
21. How much
bodily
pain have you had during the
past 4 weeks
?
1 – None
2 – Very mild
3 – Mild
4 – Moderate
5 – Severe
6 – Very severe
22. During the
past 4 weeks
, how much did
pain
interfere with your normal work (including both work outside the home and housework)?
1 – Not at all
2 – A little bit
3 – Moderately
4 – Quite a bit
5 – Extremely
These questions are about how you feel and how things have been with you
during the past 4 weeks
. For each question, please give the one answer that comes closest to the way you have been feeling.
How much of the time during the
past 4 weeks
…
32. During the
past 4 weeks
, how much of the time has
your physical health or emotional problems
interfered with your social activities (like visiting with friends, relatives, etc.)?
1 – All of the time
2 – Most of the time
3 – Some of the time
4 – A little of the time
5 – None of the time
How TRUE or FALSE is
each
of the following statements for you.
Print This Page When you have completed this survey, click “Print this Page” above. Send your completed form, along with your Patient ID Number, to info@thesternbergclinic.com
Do not refresh your browser webpage or you will lose your input data.
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