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Home
Forms
IPOS-Renal Patient Version
IPOS-Renal Patient Version
IPOS-Renal Patient Version
The link you have used to access this questionnaire is incorrect
IPOS-Renal Patient Version
UniqueCode
Q1. What has been your main problems or concerns over the past week?
1.
2.
3.
Q2. Below is a list of symptoms, which you may or may not have experienced. For each symptom, please tick the box that best describes how it has affected you over the past week?
Pain
Not at all
Slightly
Moderately
Severely
Overwhelmingly
Shortness of breath
Not at all
Slightly
Moderately
Severely
Overwhelmingly
Weakness or lack of energy
Not at all
Slightly
Moderately
Severely
Overwhemingly
Nausea (feeling like you are going to be sick)
Not at all
Slightly
Moderately
Severely
Overwhelmingly
Vomiting (being sick)
Not at all
Slightly
Moderately
Severely
Overwhelmingly
Poor appetite
Not at all
Slightly
Moderately
Severely
Overwhelmingly
Constipation
Not at all
Slightly
Moderately
Severely
Overwhelmingly
Sore or dry mouth
Not at all
Slightly
Moderately
Severely
Overwhelmingly
Drowsiness
Not at all
Slightly
Moderately
Severely
Overwhelmingly
Poor Mobility
Not at all
Slightly
Moderately
Severely
Overwhelmingly
Itching
Not at all
Slightly
Moderately
Severely
Overwhelmingly
Difficultly Sleeping
Not at all
Slightly
Moderately
Severely
Overwhelmingly
Restless legs or difficulty keeping legs still
Not at all
Slightly
Moderately
Severely
Overwhelmingly
Changes in Skin
Not at all
Slightly
Moderately
Severely
Overwhelmingly
Diarrhoea
Not at all
Slightly
Moderately
Severely
Overwhelmingly
Q2. Please list any other symptoms not mentioned above, and tick the box to show how they have affected you over the past week
1.
Q2p other symptoms severity
Not at all
Slightly
Moderately
Severely
Overwhelmingly
2.
Q2q other symptoms severity
Not at all
Slightly
Moderately
Severely
Overwhelmingly
3.
Q2r other symptoms severity
Not at all
Slightly
Moderately
Severely
Overwhelmingly
Over the past week:
Q3. Have you been feeling anxious or worried about your illness or treatment?
Not at all
Occasionally
Sometimes
Most of the time
Always
Q4. Has any of your family or friends been anxious or worried about you?
Not at all
Occasionally
Sometimes
Most of the time
Always
Q5. Have you been feeling depressed?
Not at all
Occasionally
Sometimes
Most of the time
Always
Q6. Have you felt at peace?
Always
Most of the time
Sometimes
Occasionally
Not at all
Q7. Have you been able to share how you are feeling with your family or friends as much as you wanted?
Always
Occasionally
Sometimes
Occasionally
Not at all
Q8. Have you had as much information as you wanted?
Always
Most of the time
Sometimes
Occasionally
Not at all
Q9. Have any practical problems resulting from your illness been addressed? (such as financial or personal)
Problems Addressed/ No Problems
Problems Mostly Addressed
Problems Partly Addressed
Problems Hardly Addressed
Problems Not Addressed
Q10. How much time do you feel has been wasted on appointments relating to your healthcare, e.g.Waiting on transport or repeating tests
None at all
Up to half a day wasted
More than half a day wasted
Q11. How did you complete this Questionnaire?
On my Own
With help from a friend or relative
With help from a member of staff
Last Updated:
25/03/2022