Baylor Scott & White Research Institute
Department of Gastroenterology
 
We are researchers with the Department of Gastroenterology at Baylor University Medical Center in Dallas, Texas. We are conducting a research project to learn more about your experiences with ileostomy (an opening from your small intestine to the skin, not colostomy or urostomy) and would appreciate your assistance in completing a brief survey. Your responses will be completely anonymous; we will have no way of identifying you and will not be contacting you. The project is to learn about your experiences with ileostomy, what sort of problems that you may have, and how you are dealing with them.
 
This survey should take less than 5 minutes to complete if you choose to do so. The results will be shared with the United Ostomy Association of America and published in a medical journal to let doctors know what life with an ileostomy is like. You will not be asked for any personal information that might identify you and your individual answers will be confidential.
 
There are no risks or benefits to you for being in this study and you have the option to not complete the survey and not be in the study. By completing the survey, you are saying that you are willing to be in the study. Once you submit the survey, it will be impossible to take back the information.
 
If you have any questions about this project, please contact Dr. Kyle Rowe at kyle.rowe@bswhealth.org. If you have any questions about your rights as a research subject, please contact the Baylor Scott and White Research Institute Institutional Review Board office at 214-820-2687.
 
Thank you very much for considering participating! Helping us to learn more about your experiences will help doctors do a better job in caring for other patients. 
 
Sincerely,
 
Kyle Rowe, MD
Baylor University Medical Center
3600 Gaston Ave
Dallas, Texas 75246
214-820-7570
Kyle.rowe@bswhealth.org
 

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* 1. What is your age?

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* 2. What is your gender?

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* 3. Why did you undergo ileostomy?

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* 4. How long have you had an ileostomy? (in years)

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* 5. What kind of ileostomy do you have?

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* 6. Is your ileostomy permanent or temporary?

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* 7. Have you had any small intestines removed?

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* 8. How often do you have to drain your pouch? (Times per day)

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* 9. How often do you have to change (replace) your pouch? (times per week)

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* 10. How much do you spend in an average month for ileostomy supplies? (dollars)

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* 11. Have you had an of these problems with your stoma?

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* 12. Have you experienced unexpected brief periods of high output?

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* 13. Have you experienced prolonged (over 4 weeks) high ostomy output?

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* 14. Have you been hospitalized for problems relating to high output?

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* 15. What foods increase your ileostomy output?

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* 16. Do any foods decrease your ileostomy output?

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* 17. Have you had to modify your diet in order to decrease output?

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* 18. Do you regularly use over the counter medications to reduce your ileostomy output?

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* 19. What medications? (If you answered yes to question 18)

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* 20. Do you use prescription medications to reduce your ileostomy output?

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* 21. What medications? (If you answered yes to question 20)

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* 22. Do you regularly work with an enterostomal therapy nurse (a specially trained nurse who deals with ostomies)?

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* 23. Any additional comments that you want to share with doctors taking care of patients with an ileostomy?

0 of 23 answered
 

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