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Dialysis Symptom Index: The University of Pittsburgh Medical Center

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Mahir Yousuff

This document is a patient questionnaire from the University of Pittsburgh Medical Center and VA Pittsburgh Healthcare System that assesses 30 common physical and emotional symptoms experienced by patients undergoing dialysis treatment. For each symptom, patients are asked to indicate if they experienced the symptom in the past week and, if so, how much it bothered them on a 5-point scale. The questionnaire aims to evaluate dialysis-related symptoms and their impact on patients' quality of life.

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Dialysis Symptom Index: The University of Pittsburgh Medical Center

Uploaded by

Mahir Yousuff
49 views4 pages
This document is a patient questionnaire from the University of Pittsburgh Medical Center and VA Pittsburgh Healthcare System that assesses 30 common physical and emotional symptoms experienced by patients undergoing dialysis treatment. For each symptom, patients are asked to indicate if they experienced the symptom in the past week and, if so, how much it bothered them on a 5-point scale. The questionnaire aims to evaluate dialysis-related symptoms and their impact on patients' quality of life.

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DSI

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This document is a patient questionnaire from the University of Pittsburgh Medical Center and VA Pittsburgh Healthcare System that assesses 30 common physical and emotional symptoms experienced by patients undergoing dialysis treatment. For each symptom, patients are asked to indicate if they experienced the symptom in the past week and, if so, how much it bothered them on a 5-point scale. The questionnaire aims to evaluate dialysis-related symptoms and their impact on patients' quality of life.

Copyright:

© All Rights Reserved
Download as PDF, TXT or read online from Scribd
Download as pdf or txt
49 views4 pages

Dialysis Symptom Index: The University of Pittsburgh Medical Center

Uploaded by

Mahir Yousuff
This document is a patient questionnaire from the University of Pittsburgh Medical Center and VA Pittsburgh Healthcare System that assesses 30 common physical and emotional symptoms experienced by patients undergoing dialysis treatment. For each symptom, patients are asked to indicate if they experienced the symptom in the past week and, if so, how much it bothered them on a 5-point scale. The questionnaire aims to evaluate dialysis-related symptoms and their impact on patients' quality of life.

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© All Rights Reserved
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Dialysis Symptom Index

The University of Pittsburgh Medical Center

VA Pittsburgh Healthcare System

Patient Id: _______________


Today’s Date: _______________
Code: _______________
Interviewer Id: _______________
Instructions
Below is a list of physical and emotional symptoms that people on dialysis may
have. For each symptom, please indicate if you had the symptom during the past
week by circling “yes” or “no.” If “yes”, please indicate how much that symptom
bothered you by circling the appropriate number.

If “yes”:
During the past week: How much did it bother you?
Did you experience this
A
symptom? Not Some- Quite Very
Little
At All what a Bit Much
Bit
1. Constipation NO
YES → 1 2 3 4 5
2. Nausea NO
YES → 1 2 3 4 5
3. Vomiting NO
YES → 1 2 3 4 5
4. Diarrhea NO
YES → 1 2 3 4 5
5. Decreased appetite NO
YES → 1 2 3 4 5
6. Muscle cramps NO
YES → 1 2 3 4 5
7. Swelling in legs NO
YES → 1 2 3 4 5
8. Shortness of breath NO
YES → 1 2 3 4 5
9. Lightheadedness or NO
dizziness
YES → 1 2 3 4 5
10. Restless legs or NO
difficulty keeping
legs still YES → 1 2 3 4 5

1
If “yes”:
During the past week: How much did it bother you?
Did you experience this
A
symptom? Not Some- Quite Very
Little
At All what a Bit Much
Bit
11. Numbness or
tingling in feet NO
YES → 1 2 3 4 5
12. Feeling tired or lack NO
of energy
YES → 1 2 3 4 5
13. Cough NO
YES → 1 2 3 4 5
14. Dry mouth NO
YES → 1 2 3 4 5
15. Bone or joint pain NO
YES → 1 2 3 4 5
16. Chest pain NO
YES → 1 2 3 4 5
17. Headache NO
YES → 1 2 3 4 5
18. Muscle soreness NO
YES → 1 2 3 4 5
19. Difficulty NO
concentrating
YES → 1 2 3 4 5
20. Dry skin NO
YES → 1 2 3 4 5
21. Itching NO
YES → 1 2 3 4 5
22. Worrying NO
YES → 1 2 3 4 5

2
If “yes”:
During the past week: How much did it bother you?
Did you experience this
symptom? A
Not Some Quite Very
Little
At All -what a Bit Much
Bit
23. Feeling nervous NO
YES → 1 2 3 4 5
24. Trouble falling NO
asleep
YES → 1 2 3 4 5
25. Trouble staying
NO
asleep
YES → 1 2 3 4 5
26. Feeling irritable NO
YES → 1 2 3 4 5
27. Feeling sad NO
YES → 1 2 3 4 5
28. Feeling anxious NO
YES → 1 2 3 4 5
29. Decreased interest NO
in sex
YES → 1 2 3 4 5
30. Difficulty becoming NO
sexually aroused
YES → 1 2 3 4 5

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