Your experience with your Pudendal Nerve Release Surgery

Please complete all questions

Please answer the questions of the Health Survey completely, honestly, and without interruptions. Your name will be removed and your data will be de-identified to be used for analysis and comparison with your survey before your surgery.

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* 1. Comparing how you feel now to the first year after your pudendal release surgery, has there been any change in your pain?

	Significantly improved	Somewhat improved	No change	Somewhat worse	Significantly worse
Please select	Please select Significantly improved	Please select Somewhat improved	Please select No change	Please select Somewhat worse	Please select Significantly worse

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* 2. Comparing how you feel now to the first year after your pudendal release surgery, has there been any change in your quality of life?

	Significantly improved	Somewhat improved	No change	Somewhat worse	Significantly worse
Please select	Please select Significantly improved	Please select Somewhat improved	Please select No change	Please select Somewhat worse	Please select Significantly worse

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* 3. Please rate your overall pain as you feel it today

0 No pain

Pain as bad as you can imagine 10

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 4. Please describe the character of your pain (the quality or what it feels like)

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* 5. Where is your worst area of pain?

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* 6. How frequently do you experience pain?

	All of the time	Most of the time	Some of the time	A little of the time	None of the time
Please tick	Please tick All of the time	Please tick Most of the time	Please tick Some of the time	Please tick A little of the time	Please tick None of the time

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* 7. In general, would you say your health is

	Excellent	Very good	Good	Fair	Poor
Please select	Please select Excellent	Please select Very good	Please select Good	Please select Fair	Please select Poor

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* 8. Compared to one year ago, how would you rate your health in general now?

	Much better now than one year ago	Somewhat better than one year ago	About the same	Somewhat worse than one year ago	Much worse than one year ago
Please select	Please select Much better now than one year ago	Please select Somewhat better than one year ago	Please select About the same	Please select Somewhat worse than one year ago	Please select Much worse than one year ago

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* 9. The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?

	Yes, Limited a lot	Yes, Limited a little	No, Not limited at all
Vigorous activities, such as running , lifting heavy objects, participating in strenuous sports.	Vigorous activities, such as running , lifting heavy objects, participating in strenuous sports. Yes, Limited a lot	Vigorous activities, such as running , lifting heavy objects, participating in strenuous sports. Yes, Limited a little	Vigorous activities, such as running , lifting heavy objects, participating in strenuous sports. No, Not limited at all
Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf	Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf Yes, Limited a lot	Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf Yes, Limited a little	Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf No, Not limited at all
Lifting or carrying groceries	Lifting or carrying groceries Yes, Limited a lot	Lifting or carrying groceries Yes, Limited a little	Lifting or carrying groceries No, Not limited at all
Climbing several flights of stairs	Climbing several flights of stairs Yes, Limited a lot	Climbing several flights of stairs Yes, Limited a little	Climbing several flights of stairs No, Not limited at all
Climbing one flight of stairs	Climbing one flight of stairs Yes, Limited a lot	Climbing one flight of stairs Yes, Limited a little	Climbing one flight of stairs No, Not limited at all
Bending, kneeling, or stooping	Bending, kneeling, or stooping Yes, Limited a lot	Bending, kneeling, or stooping Yes, Limited a little	Bending, kneeling, or stooping No, Not limited at all
Walking more than a kilometre	Walking more than a kilometre Yes, Limited a lot	Walking more than a kilometre Yes, Limited a little	Walking more than a kilometre No, Not limited at all
Walking several hundred metres	Walking several hundred metres Yes, Limited a lot	Walking several hundred metres Yes, Limited a little	Walking several hundred metres No, Not limited at all
Walking one hundred metres	Walking one hundred metres Yes, Limited a lot	Walking one hundred metres Yes, Limited a little	Walking one hundred metres No, Not limited at all
Bathing or dressing yourself	Bathing or dressing yourself Yes, Limited a lot	Bathing or dressing yourself Yes, Limited a little	Bathing or dressing yourself No, Not limited at all
Sitting	Sitting Yes, Limited a lot	Sitting Yes, Limited a little	Sitting No, Not limited at all
Sex	Sex Yes, Limited a lot	Sex Yes, Limited a little	Sex No, Not limited at all

Other (please specify)

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* 10. 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 physical health?

	Yes	No
Cut down the amount of time you spent on work or other activities	Cut down the amount of time you spent on work or other activities Yes	Cut down the amount of time you spent on work or other activities No
Accomplished less than you would like	Accomplished less than you would like Yes	Accomplished less than you would like No
Were limited in the kind of work or other activities	Were limited in the kind of work or other activities Yes	Were limited in the kind of work or other activities No
Had difficulty performing the work or other activities (for example, it took extra effort)	Had difficulty performing the work or other activities (for example, it took extra effort) Yes	Had difficulty performing the work or other activities (for example, it took extra effort) No

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* 11. 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)?

	Yes	No
Cut down the amount of time you spent on work or other activities	Cut down the amount of time you spent on work or other activities Yes	Cut down the amount of time you spent on work or other activities No
Accomplished less than you would like	Accomplished less than you would like Yes	Accomplished less than you would like No
Did work or other activities less carefully than usual	Did work or other activities less carefully than usual Yes	Did work or other activities less carefully than usual No

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* 12. 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?

	Not at all	Slightly	Moderately	Quite a bit	Extremely
Please select	Please select Not at all	Please select Slightly	Please select Moderately	Please select Quite a bit	Please select Extremely

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* 13. How much bodily pain have you had during the past 4 weeks?

	None	Very mild	Mild	Moderate	Severe	Very severe
Please tick	Please tick None	Please tick Very mild	Please tick Mild	Please tick Moderate	Please tick Severe	Please tick Very severe

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* 14. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)?

	Not at all	A little bit	Moderately	Quite a bit	Extremely
Please select	Please select Not at all	Please select A little bit	Please select Moderately	Please select Quite a bit	Please select Extremely

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* 15. 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..

	All of the time	Most of the time	A good bit of the time	Some of the time	A little bit of the time	None of the time
Did you feel full of life?	Did you feel full of life? All of the time	Did you feel full of life? Most of the time	Did you feel full of life? A good bit of the time	Did you feel full of life? Some of the time	Did you feel full of life? A little bit of the time	Did you feel full of life? None of the time
Have you been very nervous?	Have you been very nervous? All of the time	Have you been very nervous? Most of the time	Have you been very nervous? A good bit of the time	Have you been very nervous? Some of the time	Have you been very nervous? A little bit of the time	Have you been very nervous? None of the time
Have you felt so down in the dumps that nothing could cheer you up?	Have you felt so down in the dumps that nothing could cheer you up? All of the time	Have you felt so down in the dumps that nothing could cheer you up? Most of the time	Have you felt so down in the dumps that nothing could cheer you up? A good bit of the time	Have you felt so down in the dumps that nothing could cheer you up? Some of the time	Have you felt so down in the dumps that nothing could cheer you up? A little bit of the time	Have you felt so down in the dumps that nothing could cheer you up? None of the time
Have you felt calm and peaceful?	Have you felt calm and peaceful? All of the time	Have you felt calm and peaceful? Most of the time	Have you felt calm and peaceful? A good bit of the time	Have you felt calm and peaceful? Some of the time	Have you felt calm and peaceful? A little bit of the time	Have you felt calm and peaceful? None of the time
Did you have lots of energy?	Did you have lots of energy? All of the time	Did you have lots of energy? Most of the time	Did you have lots of energy? A good bit of the time	Did you have lots of energy? Some of the time	Did you have lots of energy? A little bit of the time	Did you have lots of energy? None of the time
Have you felt downhearted and depressed?	Have you felt downhearted and depressed? All of the time	Have you felt downhearted and depressed? Most of the time	Have you felt downhearted and depressed? A good bit of the time	Have you felt downhearted and depressed? Some of the time	Have you felt downhearted and depressed? A little bit of the time	Have you felt downhearted and depressed? None of the time
Did you feel worn out?	Did you feel worn out? All of the time	Did you feel worn out? Most of the time	Did you feel worn out? A good bit of the time	Did you feel worn out? Some of the time	Did you feel worn out? A little bit of the time	Did you feel worn out? None of the time
Have you been happy?	Have you been happy? All of the time	Have you been happy? Most of the time	Have you been happy? A good bit of the time	Have you been happy? Some of the time	Have you been happy? A little bit of the time	Have you been happy? None of the time
Did you feel tired?	Did you feel tired? All of the time	Did you feel tired? Most of the time	Did you feel tired? A good bit of the time	Did you feel tired? Some of the time	Did you feel tired? A little bit of the time	Did you feel tired? None of the time

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* 16. 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.)?

	All of the time	Most of the time	A good bit of the time	Some of the time	A little bit of the time	None of the time
Please select	Please select All of the time	Please select Most of the time	Please select A good bit of the time	Please select Some of the time	Please select A little bit of the time	Please select None of the time

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* 17. How TRUE or FALSE is each of the following statements for you?

	Definitely true	Mostly true	Don't know	Mostly false	Definitely false
I seem to get sick a little easier than other people	I seem to get sick a little easier than other people Definitely true	I seem to get sick a little easier than other people Mostly true	I seem to get sick a little easier than other people Don't know	I seem to get sick a little easier than other people Mostly false	I seem to get sick a little easier than other people Definitely false
I am as healthy as anybody I know	I am as healthy as anybody I know Definitely true	I am as healthy as anybody I know Mostly true	I am as healthy as anybody I know Don't know	I am as healthy as anybody I know Mostly false	I am as healthy as anybody I know Definitely false
I expect my health to get worse	I expect my health to get worse Definitely true	I expect my health to get worse Mostly true	I expect my health to get worse Don't know	I expect my health to get worse Mostly false	I expect my health to get worse Definitely false
My health is excellent	My health is excellent Definitely true	My health is excellent Mostly true	My health is excellent Don't know	My health is excellent Mostly false	My health is excellent Definitely false

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* 18. Do you have any additional comments about your experience with the pudendal nerve release surgery, and if you would like a follow up consultation?

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* 19. Contact Information to add to your file at WHRIA

Name

ZIP/Postal Code

Email Address

Phone Number

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* 1. Comparing how you feel now to the first year after your pudendal release surgery, has there been any change in your pain?

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* 2. Comparing how you feel now to the first year after your pudendal release surgery, has there been any change in your quality of life?

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* 3. Please rate your overall pain as you feel it today

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* 4. Please describe the character of your pain (the quality or what it feels like)

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* 5. Where is your worst area of pain?

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* 6. How frequently do you experience pain?

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* 7. In general, would you say your health is

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* 8. Compared to one year ago, how would you rate your health in general now?

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* 9. The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?

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* 10. 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 physical health?

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* 11. 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)?

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* 12. 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?

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* 13. How much bodily pain have you had during the past 4 weeks?

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* 14. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)?

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* 15. 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..

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* 16. 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.)?

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* 17. How TRUE or FALSE is each of the following statements for you?

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* 18. Do you have any additional comments about your experience with the pudendal nerve release surgery, and if you would like a follow up consultation?

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* 19. Contact Information to add to your file at WHRIA

* 15. 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..