Life Quality Questionnaire
These questions ask about the effect foot ulcers may have on your daily life and well-being. Please read each question carefully and think about the effect of your foot ulcers. Answer every question by circling one number on each line. If you are unsure about how to answer a question, please give the best answer you
Name
*
First Name
Last Name
1. How much have your foot ulcers:
*
Not at all
A little bit
Satisfied
Very Satisfied
a) stopped you from doing the hobbies and recreational activities that you enjoy
1
2
3
4
b) changed the kinds of hobbies and recreational activities that you enjoy doing
5
6
7
8
c) stopped you from going away for a weekend, vacation, or holiday
9
10
11
12
d) made you choose a different kind of weekend, vacation, or holiday than you would have preferred
13
14
15
16
e) meant you had to spend more time planning and organizing leisure activities
17
18
19
20
Type a weawe
*
None of the time
A little of the time
Satisfied
Very Satisfied
a) fatigued or tired
21
22
23
24
b) drained
25
26
27
28
c) that you had difficulty sleeping
29
30
31
32
d) pain while walking or standing
33
34
35
36
e) pain during the night
37
38
39
40
3. Because of your foot ulcers, how often have you felt:
*
None of the time
A little of the time
Some of the time
Most of the time
All of the time
a) had to depend on others to help you look after yourself (like washing and dressing)
41
42
43
44
45
b) had to depend on others to do household chores (like cooking, cleaning or laundry)
46
47
48
49
50
c) had to depend on others for getting out of the house
51
52
53
54
55
d) had to spend more time planning or organizing your daily life
56
57
58
59
60
e) felt that doing anything took longer than you would have liked
61
62
63
64
65
4. Because of your foot ulcers, how often have you felt:
*
Not at all
Slightly
Moderately
Quite a bit
Extremely
a) angry that you were not able to do what you wanted
66
67
68
69
70
b) frustrated by others doing things for you when you would rather do them yourself
71
72
73
74
75
c) frustrated because you were not able to do what you wanted
76
77
78
79
80
d) worried your ulcer(s) will never heal
81
82
83
84
85
e) worried you may have to have an amputation
86
87
88
89
90
f) worried about injury to your feet
91
92
93
94
95
g) depressed that you were not able to do what you wanted
96
97
98
99
100
h) worried about getting ulcers in the future
101
102
103
104
105
i) angry this has happened to you
106
107
108
109
110
j) frustrated because you have difficulty getting around
111
112
113
114
115
5. Because of your foot ulcers, how often were you bothered by:
*
None of the time
A little of the time
Some of the time
a) having to keep weight off your foot ulcer
116
117
118
b) the amount of time involved in caring for your foot ulcer (including dressing changes, waiting for the home health care nurse, and keeping the ulcer clean)
119
120
121
c) the appearance, odor or weeping of your ulcer
122
123
124
d) having to depend on others to help care for your foot ulcer
125
126
127
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The UK Diabetes and Diet Questionnaire
This questionnaire asks about your diet over the past month. Answer the questions by circling the letter that is most like your usual diet. Write the number of As, Bs, Cs, Ds, Es and Fs you have circled on page 4. You will be able to see whether your diet is healthy or whether you could think about some changes. There are 24 questions about your diet, please answer them all On each page think about your diet over the last MONTH. Circle the answer that best applies to you .
1. How often did you eat a portion of vegetables? Include fresh, tinned and frozen vegetables and pulses like lentils and kidney beans.
*
Please Select
Never or very rarely (F)
Once a week or less often (E)
2- 4 times a week (D)
5 - 6 times a week (C)
1 - 2 times a day (B)
3 or more times a day (A)
2. How often did you eat a portion of fruit? Include fresh, frozen, tinned and dried fruit. Do not count fruit juices.
*
Please Select
Never or very rarely (F)
Once a week or less often (E)
2- 4 times a week (D)
5 - 6 times a week (C)
1 - 2 times a day (B)
3 or more times a day (A)
3. How often did you eat a cake, a sweet pastry like a Danish pastry, a donut or a sweet biscuit?
*
Please Select
Never or very rarely (A)
Once a week or less often (B)
2- 4 times a week (C)
5 - 6 times a week (D)
1 - 2 times a day (E)
3 or more times a day (F)
4. How often did you eat sweets, chocolate or sugary foods like gulab jamun, halva or sweet popcorn?
*
Please Select
Never or very rarely (A)
Once a week or less often (B)
2- 4 times a week (C)
5 - 6 times a week (D)
1 - 2 times a day (E)
3 or more times a day (F)
5. How often did you drink sugary drinks? Include non-diet fizzy drinks, squashes, mixers, energy drinks, fruit juices, sweetened milk drinks or coffee, tea or other hot drinks with sugar or flavored syrups.
*
Please Select
Never or very rarely (A) Once a week or less often (B) 2- 4 times a week (C) 5 - 6 times a week (D) 1 - 2 times a day (E) 3 or more times a day (F)
6. How often did you use butter, ghee, lard or coconut oil or palm oil on your bread, potatoes or vegetables or in cooking?
*
Please Select
Never or very rarely (A)
Once a week or less often (B)
2-4 times a week (C)
5 -6 times a week (D)
1 -2 times a day (E)
3 or more times a day (F)
7. How often did you eat oily fish? Think about fresh or tinned salmon, trout, sardine, mackerel, pilchards, herring, red mullet, or fresh tuna.
*
Please Select
Never (F)
Less than once a week (E) Once a week (B) Twice or more per week (A)
8. How often did you drink alcohol?
*
Please Select
Never or very rarely (A) Once a week or less often (A) 2- 4 times a week (B) 5 - 6 times a week (C) 1 - 2 times a day (E) 3 or more times a day (F)
9. How often did you eat full-fat cheese? Include cheese in sandwiches, on biscuits, in sauces and when used as a topping. Include hard cheeses like cheddar, blue cheeses and soft cheeses like brie, cream cheese, pannier or full-fat goat cheeses.
*
Please Select
Never or very rarely (A)
Less than once a week (B)
1 - 2 times a week (C)
3 - 5 times a week (D)
Nearly every day or daily (E) Twice or more per day (F)
10. How often did you eat processed meat? Include processed meat in sandwiches, ready meals and if eaten as a snack. Processed meat includes foods like bacon, ham, spam, sausages, salami or chorizo.
*
Please Select
Never or very rarely (A)
Less than once a week (B)
1 - 2 times a week (C) 3 - 5 times a week (D) Nearly every day or daily (E) Twice or more per day (F)
11. How often did you eat savory foods like crisps, corn chips, corn puffs, salted nuts or Bombay mix?
*
Please Select
Never or very rarely (A)
Less than once a week (B)
1 - 2 times a week (C)
3 - 5 times a week (D)
Nearly every day or daily (E)
Twice or more per day (F)
12. How often did you eat a savory pastry? Think about food like pies, pasties, samosas, sausage rolls, patties or vol-au-vents.
*
Please Select
Never or very rarely (A)
Less than once a week (B) 1 - 2 times a week (C) 3 - 5 times a week (D) Nearly every day or daily (E) Twice or more per day (F)
13. How often did you eat 'fast foods' from a take-away or in a restaurant? Think about foods like burgers, fish and chips, fried chicken, donor kebabs, pizza, fried rice or curries with cream or ghee.
*
Please Select
Never or very rarely (A)
Less than once a week (B)
1 - 2 times a week (C)
3 - 5 times a week (D) Nearly every day or daily (E) Twice or more per day (F)
14. How often did you eat pudding or dessert, apart from fruit, with your meals?
*
Please Select
Never or very rarely (A)
Less than once a week (B) 1 - 2 times a week (C) 3 - 5 times a week (D) Nearly every day or daily (E) Twice or more per day (F)
15. How often did you have 3 or more regular meals in a day? (Include light meals like a sandwich, a soup and roll or something on toast. Don’t include snack times when you ate only a biscuit or cake or a piece of fruit or vegetable sticks or a packet of crisps or piece of cheese
*
Please Select
Never or very rarely (F)
Less than once a week (E)
Once a week (D)
2 - 4 times a week (C)
5-6 times a week (B)
Every day (A)
16. How often did you eat breakfast (more than just a drink or one or two sweet biscuits) within about 2 hours of waking?
*
Please Select
Never or very rarely (F)
Less than once a week (E)
Once a week (D)
2 - 4 times a week (C)
5-6 times a week (B)
Every day (A)
17. How often did you 'snack' or 'pick' on high-fat or high-sugar foods between meals? Think about food like biscuits, chocolate, cakes, crisps, nuts and cheese.
*
Please Select
Never or very rarely (A)
Less than once a week (B)
Once a week (C)
2 - 4 times a week (D)
5-6 times a week (E)
Every day (F)
18. How often did you eat a portion of bread? Include bread in sandwiches and wraps. A portion of bread is 1 small slice of bread, a bread roll, half a baguette, a bagel, a pikelet a tortilla wrap, a small naan, a chapatti or a paratha. (Choose the answer that applies. There is no score because there is no most healthy or least healthy choice. Use this question with question 19 to see if bread could be an important source of fiber for you.)
*
Please Select
Never or very rarely Once a week or less than once a week 2- 6 times a week 1 – 2 times a day 3 – 4 times a day More than 4 times a day
19. When you ate bread did you choose higher fiber breads? (Breads that are high in fiber include wholemeal, granary or wholegrain wheat and rye breads. If you follow a gluten free diet include high fiber gluten free breads. )
*
Please Select
All of the time (A)
Most of the time (B)
About half the time (C) Less than half the time (D) Never (E) I did not eat bread (no score)
20. How often did you eat a bowl of breakfast cereal, porridge or muesli? (Choose the answer that applies. There is no score because there is no most healthy or least healthy choice. Use this question with question 21 to see if cereal could be an important source of fiber for you. )
*
Please Select
Never or very rarely
Less than once a week
Once a week
2 – 5 times a week Nearly every day or daily
Twice or more per day
21. When you ate cereal did you choose higher fiber cereals? Cereals that are high in fiber include porridge, muesli, Weetabix, Shredded Wheat, multi-grain cereals and wheat or oat bran cereal.
*
Please Select
All of the time (A)
Most of the time (B)
About half the time (C)
Less than half the time (D) Never (E) I did not eat cereal (no score)
22. How often did you eat a serving of rice, pasta or noodles? A serving is 2-3 tablespoons cooked rice, cooked pasta or noodles. (Choose the answer that applies. There is no score because there is no most healthy or least healthy choice. Use this question with question 23 to see if rice, pasta or noodles could be an important source of fiber for you. )
*
Please Select
Never or very rarely
Less than once a week
Once a week
2 – 5 times a week
Nearly every day or daily
Twice or more per day
23. When you ate rice, pasta or noodles did you choose brown rice or wholegrain pasta / noodles?
*
Please Select
All of the time (A)
Most of the time (B)
About half the time (C)
Less than half the time (D)
Never (E)
I did not eat rice / noodles / pasta (no score)
24. And finally, what type of milk did you usually use, if any?
*
Please Select
Full fat (cow, goat or sheep) (F)
Semi-skimmed (cow, goat or sheep) (B)
Skimmed (cow, goat or sheep) (A) Sometimes full fat, sometimes skimmed or semi skimmed (D) Soya, oat, rice or other non- dairy milk (A) None (A)
25. Are you concerned about your weight?
*
Please Select
I am not concerned about my weightI am a little concerned about my weightI am moderately concerned about my weight I am very concerned about my weight
26.How important is it to you to change your diet?
*
Not at all important
1
2
3
Extremely important
4
1 is Not at all important, 4 is Extremely important
27. How confident are you that you could change your die
*
Not at all confident
1
2
3
4
5
6
7
8
9
Extremely confident
10
1 is Not at all confident, 10 is Extremely confident
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