ISSS Questionnaire
From Corposcindosis
Suggested Model Cover Letter, accompanying the questionnaire:
Part A:Before Surgery
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“You are due to undergo surgery to abolish your palmar oversweating.In an attempt to quantify the effect of this operation on your Quality of Life, the surgical unit, which is due to perform the operation, is asking you to kindly reply to the following questionnaire.A second questionnaire will be submitted to you twice, three and eighteen months after the operation.
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We would be grateful if you could complete this questionnaire and submit your answer before the operation.We shall also appreciate your further cooperation in replying to the two succeeding questionnaires, which will be submitted to you postoperatively.The answers and any additional data will be analyzed and may provide important information as to the efficacy of this procedure.The information will be kept entirely anonymous, and we would like to stress that at no point will your identity and patient confidentiality be breached.
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We thank you in advance for your time, patience and cooperation.”
Part B:After Surgery
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“You have undergone a surgery to abolish your palmar oversweating.In an attempt to quantify the effect of this operation on your Quality of Life, you have already replied to a previous questionnaire on the subject.The surgical unit, which has performed the operation, is asking you to kindly reply now to the following questionnaire.
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We would be grateful if you could complete this questionnaire and submit your answer.The answers and any additional data will be analyzed and may provide important information as to the efficacy of this procedure.The information will be kept entirely anonymous, and we would like to stress that at no point will your identity and patient confidentiality be breached.
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We thank you in advance for your time, patience and cooperation.”
Remark:The letters are to be send in the name of the Registry for Upper Thoracic Sympathetic Surgery.Once decided upon, the letters should be amended in a way to explain why the Registry is sending the second and third questionnaire and asking for the reply.
Q U E S T I O N N A I R E
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Quality of Life Disturbances Due to Palmar Hyperhidrosis
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* 1 PartA:Before Surgery
* 2 Mailing Address: …………………………………………………………………………………….
o 2.1
o 2.2
o 2.3 PartB:3 Months AfterSurgery
* 3 Mailing Address: …………………………………………………………………………………….
o 3.1 PartC:18 Months AfterSurgery
* 4 Mailing Address: …………………………………………………………………………………….
PartA:Before Surgery
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1.General Remarks:
1.1The purpose of this questionnaire is to standardize the evaluation of the disturbances caused by palmar hyperhidrosis.The patient is kindly asked to reply to the questionnaire before undergoing upper thoracic sympathectomy.Further details about the study are given in the cover letter accompanying the questionnaire.It is emphasized that the questionnaire will be kept strictly confidential.
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1.2The scale given for each answer is 1 to 4, the meaning of each grade being:
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1 =No disturbance/Excellent/Very good response
2=Some disturbance/Good/Certain response
3=Exceeding disturbance/Poor/No response
4=Unbearable disturbance/Unbearable/Worse result
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2.Identification of the Patient (Strictly confidential)
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Family Name: ………………………First Name: …………………Date of birth: ……… Mailing Address: …………………………………………………………………………………….
Telephone No.:… /…………… Fax No.: … / …………… E-mail: …………@………………..
Occupation: ………………………………………Sex: M / FHeight: ……cmWeight: …… Kg
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3.General Information
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3.1 Since when do you have from palmar oversweating? ………………………………………
3.2 Since when are you disturbed from palmar oversweating? …………………………………
3.2 Grade the amount of perspiration in the following other parts of the body (please, answer all sites):
Right
Left
a.
Hands
1 2 3 4
1 2 3 4
b.
Armpits (underarms)
1 2 3 4
1 2 3 4
c.
Face /Head
1 2 3 4
1 2 3 4
d.
Scalp
1 2 3 4
1 2 3 4
e.
Chest
1 2 3 4
1 2 3 4
f.
Back
1 2 3 4
1 2 3 4
g.
Belly
1 2 3 4
1 2 3 4
h.
Buttocks
1 2 3 4
1 2 3 4
i.
Thighs
1 2 3 4
1 2 3 4
j.
Legs
1 2 3 4
1 2 3 4
k.
Feet
1 2 3 4
1 2 3 4
3.4 What treatments have you received in the past?Grade the effect you had from each of them:
Type of Treatment
Specified Type
Did you receive?
Response
Medicines
1.
Yes / No / Don't know
1 2 3 4
2.
Yes / No / Don't know
1 2 3 4
Iontophoresis
Yes / No
1 2 3 4
Injection nerve blocks
Yes / No
1 2 3 4
Botulinum toxin injection
Yes / No
1 2 3 4
Other
Yes / No
1 2 3 4
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Give any further verbal information about these treatments.If they were effective, for how long were effective? Why did you decide to be operated? Etc.
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
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4.FunctionalDomain
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With relation to the following items, how would you rate the quality of your life in this domain?
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4.1Writing and performing paper work1 2 3 4
4.2Performing manual work / tasks with tools 1 2 3 4
4.3Other (specify) ………………………………………………………………1 2 3 4
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5.Social Domain
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With relation to the following items, how would you rate the quality of your life in this domain?
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5.1Shaking hands1 2 3 4
5.2Having intimate contact1 2 3 4
5.3Other (specify) ……………………………………………………………….. 1 2 3 4
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6.General Evaluation
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Generally speaking, how would you rate the quality of your life:
6.1The problem of oversweating being excluded?1 2 3 4
6.2The problem of oversweating being included?1 2 3 4 PartB:3 Months AfterSurgery
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1.General Remarks:
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1.1The purpose of this questionnaire is to standardize the evaluation of the effect of surgery on palmar hyperhidrosis.The patient is kindly asked to reply to the questionnaire three months after undergoing surgery.Further details about the study are given in the cover letter accompanying the questionnaire.It is emphasized that the questionnaire will be kept strictly confidential.
1.2The scale given for each answer is 1 to 4, the meaning of each grade being:
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1=Totally dry/Excellent/Completely satisfied
2=Improved/Good/Satisfied
3=Unimproved/Average/Unsatisfied
4=Worsened/Poor/Regret surgery
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2.Identification of the Patient (Strictly confidential)
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Family Name: ………………………First Name: …………………Date of birth: ……… Mailing Address: …………………………………………………………………………………….
Telephone No.:… /…………… Fax No.: … / …………… E-mail: …………@………………..
Occupation: ………………………………………Sex: M / FHeight: ……cmWeight: …… Kg
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3.General Information
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3.1Grade the amount of perspiration following surgery in the following parts of the body (please, answer all sites):
Right
Left
a.
Hands
1 2 3 4
1 2 3 4
b.
Armpits (underarms)
1 2 3 4
1 2 3 4
c.
Face /Head
1 2 3 4
1 2 3 4
d.
Scalp
1 2 3 4
1 2 3 4
e.
Chest
1 2 3 4
1 2 3 4
f.
Back
1 2 3 4
1 2 3 4
g.
Belly
1 2 3 4
1 2 3 4
h.
Buttocks
1 2 3 4
1 2 3 4
i.
Thighs
1 2 3 4
1 2 3 4
j.
Legs
1 2 3 4
1 2 3 4
3.2What side effects did you have after surgery?Grade the disturbance it causes:
3.2.1Drop of eyelidRight:1 2 3 4Left:1 2 3 4
3.2.2Pain in the chest / Shoulders / ArmsRight:1 2 3 4Left:1 2 3 4
3.2.3Other (specify): ………………………………………………………………………………
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
3.3Do you have increased perspiration in response to:
3.3.1 specific smells1 2 3 4
specify where ………………………………………………………………………..
3.3.2specific tastes1 2 3 4
specify where ………………………………………………………………………..
3.4Do you have too dry handsYes / No
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4.FunctionalDomain
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With relation to the following items, how would you rate the quality of your life in this domain?
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4.1Writing and performing paper work1 2 3 4
4.2Performing manual work / tasks with tools 1 2 3 4
4.3Other (specify) ………………………………………………………………1 2 3 4
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5.Social Domain
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With relation to the following items, how would you rate the quality of your life in this domain after surgery?
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5.1Shaking hands1 2 3 4
5.2Having intimate contact1 2 3 4
5.3Other (specify) ……………………………………………………………….. 1 2 3 4
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6.General Evaluation
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Generally speaking, how would you rate the quality of your today?1 2 3 4
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7.Remarks
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Please, give us any additional comments you may have:
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………....... PartC:18 Months AfterSurgery
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1.General Remarks:
1.1The purpose of this questionnaire is to standardize the evaluation of the effect of surgery on palmar hyperhidrosis.The patient is kindly asked to reply to the questionnaire eighteen months after undergoing surgery.Further details about the study are given in the cover letter accompanying the questionnaire.It is emphasized that the questionnaire will be kept strictly confidential.
1.2The scale given for each answer is 1 to 4, the meaning of each grade being:
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1=Totally dry/Excellent/Completely satisfied
2=Improved/Good/Satisfied
3=Unimproved/Average/Unsatisfied
4=Worsened/Poor/Regret surgery
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2.Identification of the Patient (Strictly confidential)
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Family Name: ………………………First Name: …………………Date of birth: ……… Mailing Address: …………………………………………………………………………………….
Telephone No.:… /…………… Fax No.: … / …………… E-mail: …………@………………..
Occupation: ………………………………………Sex: M / FHeight: ……cmWeight: …… Kg
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3.General Information
'
3.1Grade the amount of perspiration following surgery in the following parts of the body (please, answer all sites):
Right
Left
a.
Hands
1 2 3 4
1 2 3 4
b.
Armpits (underarms)
1 2 3 4
1 2 3 4
c.
Face /Head
1 2 3 4
1 2 3 4
d.
Scalp
1 2 3 4
1 2 3 4
e.
Chest
1 2 3 4
1 2 3 4
f.
Back
1 2 3 4
1 2 3 4
g.
Belly
1 2 3 4
1 2 3 4
h.
Buttocks
1 2 3 4
1 2 3 4
i.
Thighs
1 2 3 4
1 2 3 4
j.
Legs
1 2 3 4
1 2 3 4
3.2What side effects did you have after surgery?Grade the disturbance it causes:
3.2.1Drop of eyelidRight:1 2 3 4Left:1 2 3 4
3.2.2Pain in the chest / Shoulders / ArmsRight:1 2 3 4Left:1 2 3 4
3.2.3Other (specify): ………………………………………………………………………………
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
3.3Do you have increased perspiration in response to:
3.3.1 specific smells1 2 3 4
specify where ………………………………………………………………………..
3.3.2specific tastes1 2 3 4
specify where ………………………………………………………………………..
3.4Do you have too dry handsYes / No
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4.FunctionalDomain
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With relation to the following items, how would you rate the quality of your life in this domain?
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4.1Writing and performing paper work1 2 3 4
4.2Performing manual work / tasks with tools 1 2 3 4
4.3Other (specify) ………………………………………………………………1 2 3 4
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5.Social Domain
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With relation to the following items, how would you rate the quality of your life in this domain after surgery?
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5.1Shaking hands1 2 3 4
5.2Having intimate contact1 2 3 4
5.3Other (specify) ……………………………………………………………….. 1 2 3 4
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6.General Evaluation
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Generally speaking, how would you rate the quality of your today? 1 2 3 4
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7.Remarks
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Please, give us any additional comments you may have:
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….......
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Part D:To be filled by the surgeon
(At least once, at post-operative day I)
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1.Details on the Operation
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1.1 Type of general anesthesia:1 lung/ 2 lungs intubation
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1.2Was the operation a:Teaching / Non-teachingprocedure
1.3 Trocars: a. Number123
b. Size(mm)A -2 3 5 7 10 Other
B -2 3 5 7 10 Other
C -2 3 5 7 10 Other
c. PositionA ……………………………………………………………...
B ………………………………………………………………
C ………………………………………………………………
1.4Operated sideRtLtBilat
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1.5Operated gangliaT1 (lower part of stellate ganglion)
T2
T3
T4
T5
T6
T7
Mark position of excision-ablation-transection-clipping
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1.6Type of procedure:
1.6.1Resection
1.6.2Ablationdiathermy-radiofrequency-cryo-harmonic scalpel-laser
1.6.3Transection diathermy-radiofrequency-cryo-harmonic scalpel -laser
1.6.4Clipping (provide type of clips): …………………………………………
Remarks:…………………………………………………………………………………………………………………………………………………………………………
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1.7Length of procedure (net – from insertion of 1st trocar to last suture)
Right side…… min
Left side…… min
Total…… min
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1.8Thoracic drainage:Rt sideYes / No
Lt sideYes / No
Reasons:Routine / Other (specify) ………………………………………………
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1.9Other remarks: ……………………………………………………………………….……………………………………………………………………………………….……………………………………………………………………………………...
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2.Intraoperative complications
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2.1BleedingSourceRt side ………………………Lt side ………………………
AmountRt side ………… mlLt side ………… ml
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2.2Lung damage (requiring drainage)Rt side Lt side
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2.3Other (specify):
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
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3.Postoperative Complications
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Specify how long after the operation it has been updated:…………..days/weeks
Remark:May be filled in several times after the operation
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3.1BleedingSourceRt side ………………………Lt side ………………………
AmountRt side ………… mlLt side ………… ml
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3.2Pneumothorax (requiring drainage)Rt sideLt side
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3.3Other (specify):
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
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4.Postoperative Sequelae
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Period of time elapsed since the operation: … … weeks / months / years
Remark:For purposes of follow-up, the chapter on postoperative sequelae should be filled in repeatedly, marking each time the period of time elapsed since the operation.
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4.1Horner's syndromeRt:PtosisYes / No
MiosisYes / No
EnophthalmusYes / No
Lt:PtosisYes / No
MiosisYes / No
EnophthalmusYes / No
4.2NeuralgiaRt: Site (specify) …………………………………………………
Degree1 2 3 4 (4 - Minimal` - Severe)
Duration……… weeks / months / permanent
Lt: Site (specify) …………………………………………………
Degree1 2 3 4 (4 - Minimal1 - Severe)
Duration……… weeks / months / permanent
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3.3Compensatory Sweating: Site (specify) …………………………………………….
Degree1 2 3 4 (4 - Minimal1 - Severe)
4.4Gustatory SweatingYes / No
Phantom SweatingYes / No
WaxyHandsRt-Yes / NoLt-Yes / No
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5.Degree of Perspiration of the hands
Rt1 2 3 4 Lt1 2 3 4
(4 – totally dry1 – unchanged by surgery)
