Page 34 - Support Magazine Winter 2017
P. 34

20. Which country do you live in? Choose one option.
            Ireland         Malta        United Kingdom        Other country, namely
        21. What is your gender?      Male           Female                      22. Year of birth

        23. Which full-time education have you completed? Choose one option.
            No school                                   Secondary school                              Vocational training/apprenticeship
            Primary school                            Higher education

        24. What is your current marital status? Choose one option.
            Married          Widowed           Living together         Single         Divorced

        25. What is your current employment status? Choose one of the 7 options below.
            Student Skip to Question 30.                                           Unemployed Skip to Question 30.
            House wife/ house husband Skip to Question 30.            Receiving a disability allowance or pension Skip to Question 30.
            Employed (including self-employed) and working      Retired Skip to Question 30.
            Employed but on sick leave

        26. In a normal week, how many hours do you have a paid job (including self-employed) for?        hours
        27. How do you rate your current work ability with respect to the PHYSICAL demands of your work?
           Please circle the correct number.
                 0              1               2              3               4               5              6                 7                8               9               10
           (very poor)                                                                                                                (very good)

        28. How do you rate your current work ability with respect to the MENTAL demands of your work?
           Please circle the correct number.
                 0              1               2              3               4               5              6                 7                8               9               10
           (very poor)                                                                                                                                                                             (very good)
        29. Assume that your work ability at its best has a value of 10 points. How many points would you give your
           current work ability? (0 means that you currently cannot work at all)
           Please circle the correct number.
                 0              1               2              3               4               5              6                 7                8               9               10
           (very poor)                                                                                                                                                                             (very good)
        30. Did your employment status change due to starting treatment for end-stage kidney disease?
            Yes. If Yes, please choose one of the 7 options below.                        No
            I stopped working/retired            I changed my job          I reduced my working hours
            I was fired                                   I restarted working        I increased my working hours
            I received a disability allowance or pension
        31. Do you currently have one of the following conditions? Choose Yes or No per condition..
                                                         Yes      No                                                  Yes      No
           Diabetes mellitus                                Glomerulonephritis
           Polycystic kidney disease                     Malignancy
        32. When starting your FIRST treatment, did you understand that your kidneys had (almost) stopped working?
            Yes     No

        33. What is the average one-way travel time to your current hospital or dialysis clinic?
            Less than 30 minutes        30-60 minutes          1 -2 hours   More than 2 hours
        34. Did you get help to fill out this questionnaire?
            No, I did it myself           Yes, a doctor or nurse helped me   Yes, another person helped me
        35. Where did you find this questionnaire? Choose one option.
            Via my kidney patients organisation                             Via my nephrologist          Via another kidney patient
            Via internet or social media (Facebook, Twitter)            Other

        Remarks












                                          Please return this completed questionnaire to:
                           IKA, DONOR HOUSE, FREEPOST, BLOCK 43A, PARK WEST, DUBLIN D12 P5V6
                                         Thank you very much for your participation!
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