AMPUTATION QUESTIONNAIRE

  1. Your age:________(years)
  2. Your sex: M_______ F_______
  3. Number of years since your amputation:______(years)
  4. Reason for amputation (check all that apply):
    1. Combat wound:______
    2. Result of combat injury:______
    3. Non-combat vehicle accident:______
    4. Non-combat injury not related to a vehicle:______
    5. Other (what?): ________________________________________________
  5. Which limb(s) was removed (check all that apply)?
      right arm____ left arm____ right leg____ left leg____
  6. Do you still have the knee or elbow of the amputated limb(s)?_______(y/n)

TO
RATE
PAIN
When asked about how much pain you feel (how much you hurt), please rate the pain on a scale which starts at 0 (no pain) and continues up to 10 (so much pain you could not bear it for one more second). The higher the number, the greater the pain.

STUMP
PAIN
The following questions are about STUMP PAIN. Please reply only about pain you feel in the remaining portion of the amputated limb(s). Do not include pain in your phantom or elsewhere in your body.
Everybody feels at least some pain in their stump just after their amputation. It usually quiets down some by about six months after the amputation.

  1. About one year after your amputation:
    1. How much did your stump hurt? (use the 0-10 scale described above):
         (1) on the average? ______(0 - 10)
         (2) worst? ______(0 - 10)
         (3) least (when it hurts)? ______(0 - 10)
    2. Was your stump ever entirely pain free during this time? yes__ no__
    3. How often did your stump hurt badly enough to keep you from doing things you wanted to do (check one)?
         (1) every day:____   (2) every week:____
         (3) every two weeks:____  (4) once per month:____
         (5) less than once per month:____  (6) never:____
  2. At this time:
    1. How much does your stump hurt?
         (1) on the average? ______(0 - 10)
         (2) worst? ______(0 - 10)
         (3) least (when it hurts)? ______(0 - 10)
    2. Is your stump ever entirely free of pain? yes__ no__
    3. How often does your stump hurt enough to keep you from doing things you want to do (check one)?
         (1) every day:____  (2) once per week:____
         (3) every two weeks:____  (4) once per month:____
         (5) less than once per month:____  (6) never:____
    4. Do you ever lose sleep due to stump pain? yes____ no____
      If no, go to question e below.
      If yes:
         (1) about how many days per month does it interfere?____ (days)
         (2) about how many hours sleep do you lose on a night when it interferes? ____ (number hours)
    5. Do you ever lose work due to stump pain? yes____ no____ If no, are you currently employed? yes____ no____
           Please skip to question 9 below.
      If yes:
         (1) about how many days per month does it interfere?____ (days)
         (2) about how many hours of work per month do you lose when it interferes? ____ (number hours)
  3. What do you do to stop your stump from hurting (be specific)?

    ______________________________________________________________________

Almost everybody has non-painful sensations which seem to come from their phantoms. Most people at least occasionally feel painful sensations which seem to come from their phantoms which are called "phantom pains."
PHANTOM
PAIN
The following questions are about PHANTOM PAIN. Please reply only about pain you feel in the portion of the limb(s) which was amputated.
Do not include pain in your stump or elsewhere in your body and
Do not include normal non-painful sensations from the phantom.
If you never had any phantom pain at all, please skip to question 13.
  1. About one year after your amputation:
    1. How much did your phantom hurt:
         (1) on the average? ______(0 - 10)
         (2) worst? ______(0 - 10)
         (3) least (when it hurts)? ______(0 - 10)
    2. Was your phantom ever entirely pain free during this time?
         yes____ no____
    3. How often did your phantom hurt enough to keep you from doing things you wanted to do (check one)?
         (1) every day:____  (2) once per week:____
         (3) every two weeks:____  (4) once per month:____
         (5) less than once per month:____  (6) never:____
  2. At this time:
    1. How much does your phantom hurt?
         (1) on the average? ______(0 - 10)
         (2) worst? ______(0 - 10)
         (3) least (when it hurts)? ______(0 - 10)
    2. Is your phantom ever entirely free of pain? yes____ no____
    3. How often does your phantom hurt enough to keep you from doing things you want to do (check one)?
         (1) every day:____  (2) once per week:____
         (3) every two weeks:____  (4) once per month:____
         (5) less than once per month:____  (6) never:____
    4. Do you ever lose sleep due to phantom pain? yes____ no____
      If no, go to question e below.
      If yes:
         (1) about how many days per month does it interfere?____ (days)
         (2) about how many hours sleep do you lose on a night when it interferes? ____ (number hours)
    5. Do you ever lose work due to phantom pain? yes____ no____
      If no, please skip to question 12 below.
      If yes:
         (1) about how many days per month does it interfere?____ (days)
         (2) about how many hours of work per month do you lose when it interferes? ____ (number hours)
  3. What do you do to stop your phantom from hurting (be specific)?

    ______________________________________________________________________
  4. Have you ever used any kind of artificial limb? yes____ no____

    If NO: Why not? _______________________________________________________
    Please skip to the next question (number 14).

    If YES:
    1. About how long did it take you to learn to use your artificial limb as well as you can use it?
         ___________ (months)
    2. Do you NOW use it about the same amount you used it about one year after your amputation?    yes____ no____
         If there has been a change in your use of the prosthetic, what caused it?

         ____________________________________________________
    3. What are the major problems you have with your prosthesis?

      _______________________________________________________________

      _______________________________________________________________
    4. About how well does your prosthetic replace your living limb? (check one):    (1) almost entirely (about as good as real limb):____
         (2) about 3/4 as good (use it most of the time for most activities):____
         (3) about half as good:____
         (4) about 1/4 as good (can't wear it long enough to do much good or the limb can't do much of what is needed):______
         (5) not much good for anything:_____
    5. In what ways does your prosthetic limit your activities?
      _______________________________________________________________
    6. Does your stump hurt if you use the prosthetic for too long? yes____ no____
      If yes, does this interfere with your use of it? yes____ no____
    7. Does stump pain interfere with your use of the prosthetic? yes____ no____
    8. Does phantom pain interfere with your use of the prosthetic? yes____ no____
    9. Do you use your artificial limb regularly? yes____ no____
      If NO, why not? ______________________________________________________
      If YES: about how many hours per day do you use it?________ (hours)
    10. What do you usually use your prosthetic for? _______________________
    11. What limits your use of the prosthetic? ____________________________
    12. Does the prosthetic's socket and method of attachment cause any problems (if yes, be specific)?

      _______________________________________________________________
    13. What improvements would you like to see in the prosthetic?

      _______________________________________________________________
  5. Have you had any medical problems in your residual limb since the original amputation site healed? yes____ no____
    If NO, go to the next question (number 15).
    If Yes:
    1. Please describe the problems: _____________________________________
    2. Does use of the prosthesis cause the problems? yes____ no____
    3. Does use of the prosthesis make the problems worse? yes____ no____
  6. Other than your amputation, what is your current health? (check one)
    1. as good as it ever was:____
    2. good____
    3. fair (some chronic problems but not debilitated):____
    4. poor (debilitated by problems other than amputation):____


    THANK YOU VERY MUCH FOR ANSWERING THIS SURVEY

    PLEASE RETURN IT IN THE ATTACHED, PRE-PAID, PRE-ADDRESSED ENVELOPE
     

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    Last revised Tue 04/13/1999