反流性食管炎人群患病情況上海預(yù)調(diào)查問(wèn)卷doc(編輯修改稿)
2024-08-14 00:08 本頁(yè)面
【文章內(nèi)容簡(jiǎn)介】 : 1非常好 2好 3一般 4差 5很差Overall, how would you rate your daily activity? 1Very good 2Good 3Moderate 4Bad 5Very BadQ1017總體來(lái)說(shuō)，您從事工作的能力: 1非常好 2好 3一般 4差 5很差Overall, how would you rate your daily work?: 1Very good 2Good 3Moderate 4Bad 5Very BadQ1018總體來(lái)說(shuō)，您的精神狀態(tài): 1非常好 2好 3一般 4差 Overall, how would you rate your spirit? 1Very good 2Good 3Moderate 4Bad 5Very BadQ1019總體來(lái)說(shuō)，您的社會(huì)交往情況: 1非常好 2好 3一般 4差 5很差Overall, how would you rate your interpersonal activities? 1Very good 2Good 3Moderate 4Bad 5Very BadQ1020你是否被醫(yī)生診斷為以下情況/疾??？（如果是，最早做出這一診斷是在您多大年紀(jì)時(shí)？）Have you been diagnosed by a physician with any of the following conditions/diseases?？（If yes, at which age was it first diagnosed）年齡（歲）Age（yrs）Q1020a高血壓 HypertensionQ1020b缺血性心臟病 Ischemic heart diseaseQ1020c腦血管功能異常 Cerebrovascular disorderQ1020d糖尿病 DiabetesQ1020e慢性阻塞性肺病 COPDQ1020f哮喘 AsthmaQ1020g腎功能異常 Renal disorderQ1020h肝功能異常 Liver disorderQ1020i風(fēng)濕性關(guān)節(jié)炎 Rheumatoid arthritisQ1020j骨關(guān)節(jié)炎 OsteoarthritisQ1020k焦慮癥 AnxietyQ1020l抑郁癥 DepressionQ1021您現(xiàn)在正在服下列藥嗎？如果有，請(qǐng)?jiān)诤竺鎸?xiě)出已服用了多久Are you taking following drugs currently? If yes, please write the duration that you have taken them?時(shí)間(月)Duration(months)Q1021a皮質(zhì)類(lèi)固醇 CorticosteroidsQ1021b荷爾蒙替代品 Hormone replacementQ1022現(xiàn)在服用的其它藥物一，名稱(chēng)： Others (name)：__________ 如不知英文名，可用中文填寫(xiě)。 Q1022a服用了多少時(shí)間(月) Duration of treatment(months)Q1023現(xiàn)在服用的其它藥物二，名稱(chēng)： Others (name)：___________ Q1023a服用了多少時(shí)間(月) Duration of treatment(months)Q1024現(xiàn)在服用的其它藥物三，名稱(chēng)： Others (name)：___________ Q1024a服用了多少時(shí)間(月) Duration of treatment(months) 第二部分：SF36健康調(diào)查問(wèn)卷Part Ⅱ: SF36本調(diào)查涉及你對(duì)自身健康的觀點(diǎn)。這些信息將有助于追蹤你從事日?；顒?dòng)的能力及自身感覺(jué)。請(qǐng)回答所有問(wèn)題，在方框內(nèi)填下你所選擇的的數(shù)字。如果你對(duì)答案不確定，請(qǐng)給出你認(rèn)為最接近的答案。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 every question by marking the answer as indicated. If you are unsure about how to answer a question, please give the best answer you can.Q6001總的來(lái)說(shuō)，你認(rèn)為你的健康狀況： 1棒極了 2很好 3好 4過(guò)得去 5糟糕In general, would you say your health is: 1Excellent 2Very good 3Good 4Fair 5PoorQ6002與一年前相比，你如何評(píng)價(jià)現(xiàn)在的健康狀況？1比一年前好多了 2比一年前好一點(diǎn) 3和一年前差不多4比一年前差一點(diǎn) 5比一年前差多了Compared to one year ago, how would you rate your health in general now?1Much better now than one year ago 2Somehwat better now than one year ago 3About the same as one year ago 4Somewhat worsenow than one year ago 5Much worse
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