Please complete and submit this questionnaire at the end of your inpatient stay. Many Thanks.

PhysRehaECCA – Questionaire before discharge Site -1-

Questionnaire before discharge

First of all, thank you for your participation. This questionnaire is used to assess your genesis after starting your current cancer therapy. Their answers help to improve the quality of the course. By signing, you agree that your data will be used anonymously for research purposes.

Please read each question carefully and tick the answer option that applies to you. If you are unsure of your answer, tick the answer that is most appropriate.

Study ID:

Surname:

First name:

Date of birth:

Email:

Telefon:

Beginning of the exercises:

1. Height: 2. Body weight before the start of therapy: 3. Current body weight: (a scale is available at the station) 4. (former) job: 5. What is your highest level of education?

a. lower secondary school leaving certificate □ b. high school □ c. College degree □ d. high school graduation □ e. Graduation university □ f. Other graduation □ g. School finished without graduation □

6. Physical stress in everyday life / work?

Easy hard

Example:

8. Before starting therapy my current fitness was ...

Please complete and submit this questionnaire at the end of your inpatient stay. Many Thanks.

PhysRehaECCA – Questionaire before discharge Site -2-

7. My performance profile before starting the therapy: a. Hardly any movement in everyday life □ b. Active everyday life □ c. Walks and rarely sports □ d. Recreational athletes (1-2x per week) □ e. Ambitious athlete (3-4x per week) □ f. athlete (sports almost every day) □

8. smoker before the start of therapy?

a. Never □ b. No more □ c. Not regulary □ d. Smoker □

9. Before starting therapy my current fitness was ...

Very bad excellent

10. Did you have musculoskeletal problems before starting therapy? Yes □ / No □ 11. If yes - which ones? (Bones, tendons, joints, ligaments)

12. Previous operations:

13. Current medikation:

14. Are there general illnesses? Yes □ / No □

a. Allergies? b. Cardiovascular system (e.g. hypertension)? c. Musculoskeletal system (for example on muscles or joints)? d. Metabolism system (for example diabetes)? e. Respiratory system (e.g. asthma or chronic bronchitis)?

15. Did you experience any pain before starting therapy? not at all very strong

16. Did you have pain after starting therapy?

not at all very strong

17. If so, did the pain improve during the course?

not at all very clearly

18. Did you experience tiredness or listlessness after starting therapy?

not at all very strong

19. Did you experience anxiety, restlessness or nervousness after starting therapy?

not at all very strong

Please complete and submit this questionnaire at the end of your inpatient stay. Many Thanks.

PhysRehaECCA – Questionaire before discharge Site -3-

20. Did you experience lack of concentration, forgetfulness or memory problems after starting therapy?

not at all very strong

21. Did you experience sleep disturbances after starting the therapy?

not at all very strong

22. Did you experience any complaints in the respiratory system after starting therapy (eg cough, shortness of breath, pain)?

not at all very strong

23. Did you experience any discomfort in the area of the heart, circulation or blood vessels after starting therapy? (eg chest pain, rapid heartbeat, dizziness, circulatory disorders)

not at all very strong

24. Did you experience any complaints in the digestive system after starting therapy? (eg nausea, cramps, bloating, constipation, diarrhea)

not at all very strong

25. Did you experience any complaints in the area of the back, muscles or joints after starting therapy? (eg limitations of mobility, tension, lumbago, numbness)

not at all very strong

26. Did you experience any neurological symptoms after starting therapy? (eg coordination, sensation, word finding or visual disturbances)

not at all very strong

27. Did you consider inpatient treatment as mentally distressing?

not at all very strong

28. During your inpatient stay, did you have a visit from friends or family?

not at all very frequently

29. Did you experience any other complications after starting therapy? Yes □ / No □ a. General situation? b. Cardiovascular system? c. Musculoskeletal system? d. Metabolic system? e. Respiratory system? f. Other?

Please complete and submit this questionnaire at the end of your inpatient stay. Many Thanks.

PhysRehaECCA – Questionaire before discharge Site -4-

30. Did you have physiotherapy support during your stay in hospital? Yes □ / No □

31. If so, how often? number: 32. Did you feel that the fitness plan contributed to your physical recovery?

not at all very strong

33. Did you feel that the fitness plan has contributed to your psychological recovery (less stress, better feeling, support, distraction)?

not at all very strong

34. Will you continue the exercises at home? Yes □ / No □ 35. Has the fitness plan motivated you to do more for your health? Yes □ / No □ 36. How would you rate your knowledge about nutrition?

very bad very good

37. How much do you pay attention to your diet?

not at all very strong

38. Suggestions / wishes:

Location/Date: Signature:

Contact Person:

J. Steegmann Resident for Oral & Maxillofacial Surgery

Specialist for oral surgerysports doctor (GOTS) Department of Oral and Maxillofacial Surgery University Hospital of RWTH Aachen (Head and Chairman: Frank Hölzle, M.D., D.M.D., Ph.D., FEBOMFS) Pauwelsstr. 30 52074 Aachen Tel.: +49-241-80 37698 Fax: +49-241-80 82 430 e-mail: jsteegmann@ukaachen.de