RESCUEicp study outcome assessment form

(for patients over 16 years of age)

Patients name:___________________ Study number / centre:___________________

Date when completing the form:________________________

Part 1. Glasgow Outcome Scale (Extended)

For each question please select the response that best describes your answer by marking the appropriate box.

Respondent (please tick): Patient alone Relative/friend/carer alone

Patient + relative/friend/carer

CONSCIOUSNESS
1. Is the head injured person able to obey simple commands, or say any words? Yes No

INDEPENDENCE IN THE HOME

2a. Is the assistance of another person at home essential every day for some activities Yes No
of daily living?
(for a No answer they should be able to look after themselves at home for 24 hours if necessary,
though they need not actually look after themselves. Independence includes the ability to plan for and
carry out the following activities: getting washed, putting on clean clothes without prompting, preparing
food for themselves, dealing with callers, and handling minor domestic crises. The person should be
able to carry out activities without needing prompting or reminding and should be capable of being left
alone overnight.)

2b. Do you need frequent help or someone to be around at home most of the time? Yes No
(for a No answer they should be able to look after themselves at home for up to 8 hours during the day
if necessary, though they need not actually look after themselves.)

2c. Was assistance at home essential before the injury. Yes No

INDEPENDENCE OUTSIDE THE HOME

3a. Are you able to shop without assistance? Yes No
(this includes being able to plan what to buy, take care of money themselves and behave appropriately
in public. They need not normally shop, but must be able to do so.)

3b. Were you able to shop without assistance before the injury? Yes No

4a. Are you able to travel locally without assistance? Yes No

(They may drive or use public transport to get around. Ability to use taxi is sufficient, provided the
person can phone for it themselves and instruct the driver.)

4b. Were you able to travel without assistance before the injury. Yes No
WORK
5a. Are you currently able to work to their previous capacity? Yes No
(if they were working before, then their current capacity for work should be at the same level. If they
were seeking work before, then the injury should not have adversely affected their chances of obtaining
work or the level of work for which they are eligible. If the patient was a student before injury then their
capacity for study should not have been adversely affected.)

5b. How restricted are they? a) b)

a) reduced work capacity
b) able to work only in sheltered workshop or non-competitive job, or
currently unable to work.

5c. Were they either working or seeking employment before the injury (answer is Yes) Yes No
or were they doing neither (answer is No).

SOCIAL AND LEISURE ACTIVITIES

6a. Are they able to resume regular social and leisure activities outside home? Yes No
(they need not have resumed all their previous leisure activities, but should not be prevented by physical
or mental impairment. If they have stopped the majority of activities because of loss of interest or
motivation than this is also considered as a No answer.)

6b. What is the extent of restriction on their social and leisure activities? a) b) c)
a) Participate a bit less: at least half as often as before injury.
b) Participate much less: less than half as often.
c) Unable to participate: rarely, if ever, take part.

6c. Did they engage in regular social and leisure activities outside home Yes No
before injury?

FAMILY AND FRIENDS

7a. Have there been psychological problems which have resulted in ongoing Yes No
family disruption or disruption to friendships?
(typical post-traumatic personality changes: quick temper, irritability, anxiety, insensitivity to others,
mood swings, depression and unreasonable or childish behaviour.)

7b. What has been the extent of disruption or strain? a) b) c)

a) occasional less then weekly
b) frequent once a week or more, but tolerable
c) constant daily and intolerable

7c. Were there problem with family or friends before injury? Yes No
(if there were some problems before injury, but these have become markedly worse since injury please
answer No.)
 EPILEPSY

7d. Since the injury have you had any epileptic fits? Yes No

7e. Have you been told that you are currently at risk of developing epilepsy? Yes No

RETURN TO NORMAL LIFE

8a. Are there any other current problems relating to the injury which affect daily life? Yes No
(other typical problems reported after head injury: headaches, dizziness, tiredness, sensitivity to noise or
light, slowness, memory failures and concentration problems.)

8b. Were similar problems present before surgery? Yes No

(if there were some problems before injury, but these have become markedly worse since injury then
please answer No.)

What is the most important factor affecting your outcome?

The effects of head injury? A

Effects of illness or injury to another part of the body? B

A mixture of these? C

Now please complete the second part of the questionnaire

Part 2.

SF36 Health Survey

This survey asks for your views about your health. This information will help keep track of how you feel and
how well you are able to do your usual activities.

For each of the following questions, please tick the one box that best describes your answer. If you are unsure
about how to answer a question, please give the best answer you can.

1. In general, would you say your health is:

Excellent Very good Good Fair Poor

1 2 3 4 5

2. Compared to one year ago, how would you rate your health in general now?

Somewhat Somewhat
Much better better About the worse Much worse
now than one now than one same as now than one now than one
year ago year ago one year ago year ago year ago

1 2 3 4 5

SF-36v2 Health Survey 1992-2002 by Health Assessment Lab, Medical Outcomes Trust and QualityMetric Incorporated. All rights reserved.
SF-36 is a registered trademark of Medical Outcomes Trust.
(IQOLA SF-36v2 Standard, English (United Kingdom) 8/02)
 3. The following questions are about activities you might do during a typical day.
Does your health now limit you in these activities? If so, how much?

Yes, Yes, No, not

limited limited limited
a lot a little at all

a Vigorous activities, such as running, lifting

heavy objects, participating in strenuous sports .................. 1 ........... 2 .......... 3

b Moderate activities, such as moving a table, pushing

a vacuum cleaner, bowling, or playing golf .......................... 1 ........... 2 .......... 3

c Lifting or carrying groceries .................................................. 1 ........... 2 .......... 3

d Climbing several flights of stairs .......................................... 1 .......... 2 .......... 3

e Climbing one flight of stairs .................................................. 1 .......... 2 .......... 3

f Bending, kneeling, or stooping ............................................. 1 ........... 2 .......... 3

g Walking more than a mile .................................................... 1 .......... 2 .......... 3

h Walking several hundred yards ............................................ 1 ........... 2 .......... 3

i Walking one hundred yards ................................................. 1 .......... 2 .......... 3

j Bathing or dressing yourself ................................................ 1 ........... 2 .......... 3

SF-36v2 Health Survey 1992-2002 by Health Assessment Lab, Medical Outcomes Trust and QualityMetric Incorporated. All rights reserved.
SF-36 is a registered trademark of Medical Outcomes Trust.
(IQOLA SF-36v2 Standard, English (United Kingdom) 8/02)
 4. During the past 4 weeks, how much of the time have you had any of the following
problems with your work or other regular daily activities as a result of your physical
health?

All of Most of Some of A little of None of

the time the time the time the time the time

a Cut down on the amount of

time you spent on work or
other activities ............................... 1 .......... 2 .......... 3 .......... 4........... 5

b Accomplished less than you

would like ...................................... 1 .......... 2 ........... 3 .......... 4........... 5

C Were limited in the kind of

work or other activities .................. 1 .......... 2 ........... 3 .......... 4........... 5

d Had difficulty performing the

the work or other activities (for
example, it took extra effort) ......... 1 .......... 2 ........... 3 .......... 4........... 5

5. During the past 4 weeks, how much of the time have you had any of the following
problems with your work or other regular daily activities as a result of any emotional
problems (such as feeling depressed or anxious)?

All of Most of Some of A little of None of

the time the time the time the time the time

a Cut down on the amount of

time you spent on work or
other activities ............................... 1 .......... 2 ........... 3 .......... 4 .......... 5

b Accomplished less than you

would like ...................................... 1 .......... 2 .......... 3 .......... 4........... 5

C Did work or other activities

less carefully than usual ............... 1 .......... 2 .......... 3 .......... 4 .......... 5

SF-36v2 Health Survey 1992-2002 by Health Assessment Lab, Medical Outcomes Trust and QualityMetric Incorporated. All rights reserved.
SF-36 is a registered trademark of Medical Outcomes Trust.
(IQOLA SF-36v2 Standard, English (United Kingdom) 8/02)
 6. During the past 4 weeks, to what extent has your physical health or emotional
problems interfered with your normal social activities with family, friends, neighbours,
or groups?

Not at all Slightly Moderately Quite a bit Extremely

1 2 3 4 5

7. How much bodily pain have you had during the past 4 weeks?

None Very mild Mild Moderate Severe Very severe

1 2 3 4 5 6

8. During the past 4 weeks, how much did pain interfere with your normal work
(including both work outside the home and housework)?

Not at all A little bit Moderately Quite a bit Extremely

1 2 3 4 5

SF-36v2 Health Survey 1992-2002 by Health Assessment Lab, Medical Outcomes Trust and QualityMetric Incorporated. All rights reserved.
SF-36 is a registered trademark of Medical Outcomes Trust.
(IQOLA SF-36v2 Standard, English (United Kingdom) 8/02)
 9. These questions are about how you feel and how things have been with you during the
past 4 weeks. For each question, please give the one answer that comes closest to
the way you have been feeling. How much of the time during the past 4 weeks

All of Most of Some of A little of None of

the time the time the time the time the time

a Did you feel full of life? ................. 1........... 2 ........... 3 .......... 4 ........... 5

b Have you been very nervous? ..... 1............ 2 ........... 3 .......... 4 ........... 5

c Have you felt so down in the

dumps that nothing could
cheer you up? .............................. 1............ 2 ........... 3 .......... 4 ............ 5

d Have you felt calm and

peaceful? ..................................... 1............ 2 ........... 3 .......... 4 ........... 5

e Did you have a lot of energy? ...... 1............ 2 ........... 3 .......... 4 ........... 5

f Have you felt downhearted

and low?....................................... 1............ 2 ............ 3 .......... 4 ............ 5

g Did you feel worn out? ................. 1............ 2 ............ 3 .......... 4 ............ 5

h Have you been happy? ................ 1............ 2 ........... 3 .......... 4 ........... 5

i Did you feel tired? ........................ 1........... 2 ........... 3 ........... 4 ........... 5

10. During the past 4 weeks, how much of the time has your physical health or
emotional problems interfered with your social activities (like visiting with friends,
relatives, etc.)?

All of Most of Some of A little of None of

the time the time the time the time the time

1 2 3 4 5

SF-36v2 Health Survey 1992-2002 by Health Assessment Lab, Medical Outcomes Trust and QualityMetric Incorporated. All rights reserved.
SF-36 is a registered trademark of Medical Outcomes Trust.
(IQOLA SF-36v2 Standard, English (United Kingdom) 8/02)
 11. How TRUE or FALSE is each of the following statements for you?

Definitely Mostly Dont Mostly Definitely

true true know false false

a I seem to get ill more

easily than other people ................ 1 .......... 2 ........... 3 .......... 4 ........... 5

b I am as healthy as
anybody I know ............................. 1 .......... 2 ............ 3 ........... 4........... 5

c I expect my health to
get worse ...................................... 1 .......... 2 ........... 3 ........... 4........... 5

d My health is excellent.................... 1 ........... 2 ........... 3 .......... 4........... 5

SF-36v2 Health Survey 1992-2002 by Health Assessment Lab, Medical Outcomes Trust and QualityMetric Incorporated. All rights reserved.
SF-36 is a registered trademark of Medical Outcomes Trust.
(IQOLA SF-36v2 Standard, English (United Kingdom) 8/02)
 Time line
Please give details of your treatment and rehabilitation, if you cant remember the exact date,
the month and year is fine.

Date transferred to the neurosurgical ward: _______________________________________

Date transferred to local hospital:_______________________________________________

Date transferred to an acute rehabilitation facility:___________________________________

Date transferred to long term rehabilitation:________________________________________

Date discharged home with a carer:_____________________________________________

Date discharged home:_______________________________________________________

Date returned to work:________________________________________________________

Current situation (location and level of support):____________________________________

__________________________________________________________________________
Further operations:

Shunt operation required: No Yes If yes, date: ____________________

Plate or bone inserted in the skull (cranioplasty): No Yes If yes, date:_________

Plate or bone removed due to infection: No Yes If yes, date:_____________

Other omments:_____________________________________________________________

__________________________________________________________________________

Thank you for completing the questionnaire!