SCIM-SPINAL CORD INDEPENDENCE MEASURE
Contents
1. 1 6 times every week O Daily 8 Medication against fecal incontinence O No O Yes 9 Flatus incontinence O No O Yes 10 Perianal skin problems O No O Yes Total NBD score range 0 47 NBD score Bowel Dysfunction 0 6 Very Minor 7 9 Minor 10 13 Moderate 14 or more Severe Points2. O 1 About once a week or less O 2 Two or Three times a week O 3 About once a day O 4 Several times a day 15 All the time 2 How much urine do you think you usually leak O 0 None O 2 A small amount O 4 A moderate amount O 6 A large amount 3 Overall how much does leaking urine interfere with your everyday life 00 O1 02 03 O4 05 o6 07 08 O9 O10 Not at A great deal ICIQ score Sum scores 1 2 3 I 4 When does urine leak Select all that apply O Never Urine does not leak O Leaks before you can get to the toilet O Leaks when cough or sneeze O Leaks when you are asleep O Leaks when you are physically active exercising O Leaks when you have finished urinating and are dressed O Leaks for no obvious reason O Leaks all the time Comments mi OU Physicians UROLOGY ICIQ August 2006 bpalmer Page 1 of 1 w Pt Initials Pt ID No OAB q Short Form Symptom Bother This questionnaire asks about how much you have been bothered by selected bladder symptoms during the past 4 weeks Please check the box that best describes the extent to which you were bothered by each symptom during the past 4 weeks There are no right or wrong answers Please be sure to answer every question During the past 4 weeks how bothered were Notat Alittle Some Quitea_ A great A very great you by all bit what bit deal deal 1 An uncomfortable urge to urinate O O O L m m 2 A sudde
3. how much energy did you have Very much Quite a lot Some A little None 6 During the past 4 weeks how much did your physical health or emotional problems limit your usual social activities with family or friends Could not do social activities Not at all Very little Somewhat Quite a lot 7 During the past 4 weeks how much have you been bothered by emotional problems such as feeling anxious depressed or irritable Not at all Slightly Moderately Quite a lot Extremely 8 During the past 4 weeks how much did personal or emotional problems keep you from doing your usual work school or other daily activities Could not do daily activities Not at all Very little Somewhat Quite a lot E EL Subj Page 1 of 4 E pate COE OU Physicians UROLOGY CLINIC Voiding Dys SIDI F Patient Name Patient name is not stored in the database Please use a pen to fill in the circle box s to indicate your choice Sexual Interest and Desire Inventory Female SIDI F INTRODUCTION The following questions are used to assess your feelings of sexual interest or desire as well as some other aspects of your sex life By sexual desire mean your interest in having a sexual experience whether alone or with a partner Sexual interest involves thoughts feelings and or a willing
4. satisfied were you with your C1 Somewhat dissatisfied overall level of sexual desire interest O Neutral Oo Somewhat satisfied o Satisfied ITEM 7 DESIRE DISTRESS O Never distressed Over the past month when you thought about sex or O Mildly distressed were approached for sex how distressed worried O Moderately distressed concerned guilty were you about your level of desire O Markedly distressed O Extremely Severely distressed E OU Physicians UROLOGY SIDI F Jan 2007 Bpalmer Page 2 of 4 E AL swe 34135 Patient name Patient name is not stored in the database Voiding Dysfunction SIDI F ITEM 8 THOUGHTS POSITIVE How often have you thought about sex over the past month When you thought about sex what was your level of interest strength of desire in having sex Page 3 of 4 E Never C Never thought associated Mild Moderate Intense about sex with desire desire desire desire 1 2 times month O O O O 3 4 times month 0O O Oo More than once a week O O O O ITEM 9 EROTICA O Not interested Over the past month how did you react to sexually O Mildly interested suggestive material e g love scenes in movies and on O Moderately interested television erotic pictures stories in magazines books Highly interested ITEM 10 AROUSAL FREQUENCY O No sexual activity Over the past month how often did you become aroused O Never become aroused sexually ex
5. tiredness or loss of energy How often did you experience fatigue tiredness or loss of energy O Absent or clinically mild tiredness loss of enerty DM ITEM 1 RELATIONSHIP GENERAL Ol Dissatisfied How satisfied are you with your relationship as a whole LI Somewhat dissatisfied O Neutral O Somewhat satisfied O Satisfied DM ITEM 2 THOUGHTS NEGATIVE Ll Never turned off felt negative Over the past month including this interview when you 1 Somewhat turned off felt somewhat negative think about having sex do you feel any of the following O Definetly turned off Strong negative feeling negative feelings turned off anxious repulsed sick DM ITEM 3 PAIN O Yes and it made me stop Over the past month did you experience genital pain O Yes but continued through the pain during sex O Yes but pain was transient Ol No pain o No sexual activity DM ITEM 4 MOOD Moderate Severe Over the past month how has Clear nonverbal Intense sadness your mood been signs of sadness hoplessness Mild feelings of about most Very Severe Feelings of hoplessness aspects of life Extreme Have you experienced any a saness helplessness or feelings of sadness feelings of sadness O Absent or clinically discouragement worthlessness complete intractable hopelessness helplessness insignificant low self esteem about some helplessness or hoplessness or worthlessness pessimism aspects of life worthlessness helplessness In
6. to reduce your physical activities O O O O O O exercising sports etc 2 3 4 5 6 8 Caused you to have problems with your O O O O O O partner or spouse 5 3 i 3 9 Made you uncomfortable while travelling with others because of needing to stop to go O O O L L m to the toilet 10 Affected your relationships with family and O O O O O O friends 1 2 3 4 5 P 11 Interfered with getting the amount of sleep O O O O O O you needed i z 3 A 2 12 Caused you embarrassment O O O O m L 13 Caused you to locate the closest toilet as soon as you arrive at a place you have never O O O O L L been Copyright 2004 Pfizer All rights reserved UK OAB gq SF ver 1 0 2004 Neurogenic Bowel Dysfunction Score The number of points for each possible answer is given in parenthesis Mark only one answer per question 1 Frequency of defecation O Daily 0 O 2 6 times every week 1 O Less than once a week 6 2 Time used for each defecation O 0 30 min 0 1131 60 min 3 OMore than one hour 7 3 Uneasiness headache or perspiration during defecation O No O Yes 4 Regular use of tablets against constipation O No O Yes 5 Regular use of drops against constipation O No O Yes 6 Digital stimulation or evacuation of the anorectum O Less than once every week O Once or more every week 7 Frequency of fecal incontinence Less than once every month O 1 4 times every month
7. EM 3 INITIATION L Did not encourage initiate Over the past month how frequently did you do anything O 1 2 times a month to encourage sex with your partner O 3 4 times a month C1 More than once a week Comments E OU Physicians UROLOGY SIDI F Jan 2007 Bpalmer Page 1 of 4 m ee s 34135 Patient Name Patient name is not stored in the database Voiding Dysfunction SIDI F Page 2 of 4 Comments ITEM 4 DESIRE FREQUENCY Over the past month how frequently GNeverwant d have you wanted to engage in some h Not intense at Mildly Moderately Extremely kind of sexual activity either with or to have sex all fleeting intense intense intense without a partner 1 2 times month O O O O How strong was your desire to engage in sex Please answer this question even if 3 4 times month OU O O O you did not actually engage in any sexual activity but were aware of wanting to be sexual in some way More than o o o o once a week ITEM 5 AFFECTION C Never wanted to have Mildly Moderately Extremely Over the past month how often have physical affection intense intense intense you wanted physical affection other than sex for example touching Less than o o o holding kissing once a week How intense would you say was your More than desire for physical affection once a week E 0 0 but not every day Daily O O O ITEM 6 DESIRE SATISFACTION O Dissatisfied Over the past month how
8. SCIM spINAL CORD INDEPENDENCE MEASURE l of 3 If form filled out in last 1 year and no changes Check here UO Please clearly circle only one answer for each question Self Care 1 Feeding cutting opening containers pouring bringing food to mouth holding cup with fluid 0 Needs parenteral gastrostomy or fully assisted oral feeding 1 Needs partial assistance for eating and or drinking or for wearing adaptive devices 2 Eats independently needs adaptive devices or assistance only for cutting food and or pouring and or opening containers 3 Eats and drinks independently does not require assistance or adaptive devices 2 Bathing soaping washing drying body and head manipulating water tap A upper body B lower body A 0 Requires total assistance 1 Requires partial assistance 2 Washes independently with adaptive devices or in a specific setting e g bars chair 3 Washes independently does not require adaptive devices or specific setting not customary for healthy people adss B 0 Requires total assistance 1 Requires partial assistance 2 Washes independently with adaptive devices or in a specific setting adss 3 Washes independently does not require adaptive devices adss or specific setting 3 Dressing clothes shoes permanent orthoses dressing wearing undressing A upper body B lower body A 0 Requires total assistance 1 Requires partial assistance with clothes without buttons zippers or laces cwob
9. bars 5 Uses toilet independently does not require adaptive devices or special setting SUBTOTAL 0 40 SCIM spINAL CORD INDEPENDENCE MEASURE 3 of 3 Mobility room and toilet 9 Mobility in Bed and Action to Prevent Pressure Sores 0 Needs assistance in all activities turning upper body in bed turning lower body in bed sitting up in bed doing push ups in wheelchair with or without adaptive devices but not with electric aids 2 Performs one of the activities without assistance 4 Performs two or three of the activities without assistance 6 Performs all the bed mobility and pressure release activities independently 10 Transfers bed wheelchair locking wheelchair lifting footrests removing and adjusting arm rests transferring lifting feet 0 Requires total assistance 1 Needs partial assistance and or supervision and or adaptive devices e g sliding board 2 Independent or does not require wheelchair 11 Transfers wheelchair toilet tub if uses toilet wheelchair transfers to and from if uses regular wheelchair locking wheelchair lifting footrests removing and adjusting armrests transferring lifting feet 0 Requires total assistance 1 Needs partial assistance and or supervision and or adaptive devices e g grab bars 2 Independent or does not require wheelchair Mobility indoors and outdoors on even surface 12 Mobility Indoors Requires total assistance Needs electric wheelchair or partial assistance to ope
10. cited wet lubricated etc O Infrequent less than half the time O Often half the time or more but not always O Always ITEM 11 AROUSAL EASE oO No sexual activity Over the past month when you had sex how easily did O Notat all aroused you become aroused sexually excited wet lubricated CO Aroused with difficulty etc in response to sexual stimulation Ol Aroused somewhat easily O_scEasily aroused ITEM 12 AROUSAL CONTINUATION o No sexual activity Over the past month once you started to become o No desire Never aroused sexually aroused did you want to receive more oO Little desire stimulation If yes how strong was your desire to be o Moderate desire further more sexually stimulated O Strong desire ITEM 13 ORGASM zi rer te Over the past month when you O No sexual activity Achieved majority Achieved majority had sex how often did you have O Not able to of orgasms with of orgasms an orgasm achieve orgasm some difficulty without difficulty Infrequent How easy wee it for you to have less than O LJ an orgasm half the time Often half the time 0 UW or more but not always Always O O Comments E OU Physicians UROLOGY SIDI F Jan 2007 Bpalmer Page 3 of 4 E MB cue 34135 Patient Name Patient name is not stored in the database Voiding Dysfunction SIDI F Page 4 of 4 Over the past month did you experience fatigue
11. eps without any support or supervision 16 Transfers wheelchair car approaching car locking wheelchair removing arm and footrests transferring to and from car bringing wheelchair into and out of car 0 Requires total assistance 1 Needs partial assistance and or supervision and or adaptive devices 2 Transfers independent does not require adaptive devices or does not require wheelchair 17 Transfers ground wheelchair 0 Requires assistance 1 Transfers independent with or without adaptive devices or does not require wheelchair OCADNBRWNK CO OAANNBWNK SO AANINDNBWNK SUBTOTAL 0 40 SF 8 Health Survey Please circle only one answer for each question 1 Overall how would you rate your health in the past 4 weeks Good Fair Excellent Very good Poor Very poor 2 During the past 4 weeks how much did physical health problems limit your usual physical activities such as walking or climbing stairs Could not do physical activities Not at all Very little Somewhat Quite a lot 3 During the past 4 weeks how much difficulty did you have doing your daily work both at home and away from home because of your physical health None at all A little bit Some Quite a lot coud monde daily work 4 How much bodily pain have you had in the past 4 weeks None Very mild Mild Moderate Severe vay Severe 5 During the past 4 weeks
12. ercise Program Anti cholinergic or Other Medical Therapy Urodynamic Evaluation Discussed Surgical Intervention Discussed Physician Signature Date Incontinence Impact Questionnaire Short Form IIQ 7 Some people find that accidental urine loss may affect their activities relationships and feelings The questions below refer to areas in your life that may have been influenced or changed by your problem For each question circle the response that best describes how much your activities relationships and feelings are being affected by urine leakage Has urine leakage affected your Not at All Slightly Moderately Greatly 1 Ability to do household chores cooking housecleaning laundry Oan Tosenene r EETAS 3 2 Physical recreation such as walking swimming or other exercise cceeeeeeees Ors og ind e Dishonest EAE Disord ah 3 3 Entertainment activities movies CONCETS CIC 7 vd z dirnwatcadzdedsadsometenaseastouerees One ferdeeders Vecccezateautss Diganta 3 4 Ability to travel by car or bus more than 30 minutes from home cccceseeeeees O EEE y EO EPEE P ATTE 3 5 Participation in social activities outside your home ccceeeeeeeeeeeeeeeeeeees Oaa Taenia AEREN 3 6 Emotional health nervousness depression ClO Pista lalate flail tele I EE ENER Tondras P AE TEE 3 7 Feeling frustrated vicocsccacecccsieecasaiecece tetas Os sree Torent EEEE 3 Items 1 a
13. frequent How often have you had such less than half your o o o o feelings waking hours Often half your waking O O 0 O hours or more but not always Alway O O O O DM ITEM 5 FATIGUE Mild Moderate to Marked prominent tiredness loss of energy fatigue feelings of ineianifi fatigue feelings of heaviness in aa insignificant limbs or being weighted down heaviness in tins ey being weighted down Infrequent less than half your O O waking hours Often half your waking Ol oO hours or more but not always Always oO oO Comments E OU Physicians UROLOGY SIDI F Jan 2007 Bpalmer Page 4 of 4 E Name INCONTINENCE QUESTIONAIRE UDI 6 Date DO YOU EXPEREINCE ANY URINARY INCONTINENCE YES NO Please circle the number that best describes what you are feeling Use the following as your guide 0 Not at All 1 Slightly 2 Moderately 3 Greatly Do you experience and if so how much are you bothered by l 2 Frequent urination 0 1 2 3 Urine leakage related to the felling of urgency 0 1 2 3 Urine leakage related to physical activity coughing or sneezing 0 1 2 3 Small amounts of urine leakage 0 1 2 3 Difficulty emptying your bladder 0 1 2 3 Pain or discomfort in the lower abdomen or genital area 0 1 2 3 For physician only Timed Voiding Double Voiding Conservative Fluid Management Kegel Ex
14. n urge to urinate with little or no O O O O O O warning 5 4 3 3 Accidental loss of small amounts of urine O O O O a a Seas si git o O O O O O 4 Nighttime urination 5 3 7i 5 6 5 Waking up at night because you had to O O O O O O urinate z 5 4 3 6 Urine loss associated with a strong desire 0O O O O O 2 3 4 5 6 to urinate UK OAB gq SF ver 1 0 2004 Pt Initials Pt ID No For the following questions please think about your overall bladder symptoms in the past 4 weeks and how these symptoms have affected your life Please answer each question about how often you have felt this way to the best of your ability Please check the box that best answers each question A good During the past 4 weeks how often have your Nope of zk Miles Some of bit of Motor SAN oE the of the the the the bladder symptoms i the x time time time time time time 1 Caused you to plan escape routes to toilets O O O O O O in public places a i i 2 Made you feel like there is something wrong O 0O O O with you 2 3 4 5 6 3 Interfered with your ability to get a good O O O O O night s rest z 4 Made you frustrated or annoyed about the O O 0O O amount of time you spend in the toilet 2 3 i R 5 Made you avoid activities away from toilets O O O O O O i e walks running hiking 2 3 5 6 O O O O O O 6 Awakened you during sleep 7 5 7 5 7 Caused you
15. nd 2 physical activity Items 3 and 4 travel Item 5 social relationships Items 6 and 7 emotional health Scoring Item responses are assigned values of 0 for not at all 1 for slightly 2 for moderately and 3 for greatly The average score of items responded to is calculated The average which ranges from 0 to 3 is multiplied by 33 1 3 to put scores on a scale of 0 to 100 Reference Uebersax J S Wyman J F Shumaker S A McClish D K Fantl J A amp the Continence Program for Women Research Group 1995 Short forms to assess life quality and symptom distress for urinary incontinence in women The incontinence impact questionnaire and the urogenital distress inventory Neurourology and Urodynamics 14 131 139 1 Tools Short Form IIQ 7 Do not reprint a EE subject 2 arel EE OU Physicians UROLOGY CLINIC IKOS KO Patient Name Patient name is not stored in the database Please use a pen to fill in the circle box s to indicate your choice ICIQ Questionnaire Itis not uncommon for people to leak urine some of the time Through your responses to this questionnaire we will be able to collect data on how many people leak urine and how much this bothers them We would be grateful if you could answer the following questions thinking about how you have been on average over the past four weeks 1 How often do you leak urine Select only one choice O 0 Never
16. ness to become involved in some sort of sexual activity Please remember that there are no right or wrong answers to the questions asked am most interested in what you feel not what you think you should feel or what you think others feel If you do not understand any of the questions please let me know The following question asks about your relationship with your partner spouse ITEM 1 RELATIONSHIP SEXUAL O Dissatisfied oe How Satisfied are you with the sexual aspect of your O Somewhat dissatisfied relationship with your partner O Neutral O Somewhat satisfied O Satisfied SEXUAL ACTIVITY O Never Over the past month approximately how many times did O 1 2 times a month you engage in sexual activity either alone or with your O 3 4 times a month partner 1 More than once a By sexual activity am referring to sexual caressing week genital stimulation including masturbation or intercourse ITEM 2 RECEPTIVITY Participated Receptive Over the past month when HO Bet a sex Participated withsome to partner s Sexually your partner approached ue AEA x solely primarily interest but approach enthusiastic and you for sex how often did O aid n u a i out of obligation little sexual interested encouraging you accept la DOT participate enthusiasm sexually When you accepted what Infrequent was your level of less than half O H m H enthusiasm the time Often half the time or more O O O O but not always Always O 0 0 E IT
17. rate manual wheelchair Moves independently in manual wheelchair Requires supervision while walking with or without devices Walks with a walking frame or crutches swing Walks with crutches or two canes reciprocal walking Walks with one cane Needs leg orthosis only Walks without walking aids 13 Mobility for Moderate Distances 10 100 meters Requires total assistance Needs electric wheelchair or partial assistance to operate manual wheelchair Moves independently in manual wheelchair Requires supervision while walking with or without devices Walks with a walking frame or crutches swing Walks with crutches or two canes reciprocal walking Walks with one cane Needs leg orthosis only Walks without walking aids 14 Mobility Outdoors more than 100 meters Requires total assistance Needs electric wheelchair or partial assistance to operate manual wheelchair Moves independently in manual wheelchair Requires supervision while walking with or without devices Walks with a walking frame or crutches swing Walks with crutches or two canes reciprocal waking Walks with one cane Needs leg orthosis only Walks without walking aids 15 Stair Management 0 Unable to ascend or descend stairs 1 Ascends and descends at least 3 steps with support or supervision of another person 2 Ascends and descends at least 3 steps with support of handrail and or crutch or cane 3 Ascends and descends at least 3 st
18. tance or stimulation for coughing 10 Breathes independently without assistance or device 6 Sphincter Management Bladder 0 Indwelling catheter 3 Residual urine volume RUV gt 100cc no regular catheterization or assisted intermittent catheterization 6 RUV lt 100cc or intermittent self catheterization needs assistance for applying drainage instrument 9 Intermittent self catheterization uses external drainage instrument does not need assistance for applying 11 Intermittent self catheterization continent between catheterizations does not use external drainage instrument 13 RUV lt 100cc needs only external urine drainage no assistance is required for drainage 15 RUV lt 100cc continent does not use external drainage instrument 7 Sphincter Management Bowel 0 Irregular timing or very low frequency less than once in 3 days of bowel movements 5 Regular timing but requires assistance e g for applying suppository rare accidents less than twice a month 8 Regular bowel movements without assistance rare accidents less than twice a month 10 Regular bowel movements without assistance no accidents 8 Use of Toilet perineal hygiene adjustment of clothes before after use of napkins or diapers 0 Requires total assistance 1 Requires partial assistance does not clean self 2 Requires partial assistance cleans self independently 4 Uses toilet independently in all tasks but needs adaptive devices or special setting e g
19. zl 2 Independent with cwobzl requires adaptive devices and or specific settings adss 3 Independent with cwobzl does not require adss needs assistance or adss only for bzl 4 Dresses any cloth independently does not require adaptive devices or specific setting B 0 Requires total assistance 1 Requires partial assistancewith clothes without buttons zippers or laces cwobzl 2 Independent with cwobzl requires adaptive devices and or specific settings adss 3 Independent with cwobzl without adss needs assistance or adss only for bzl 4 Dresses any cloth independently does not require adaptive devices or specific setting 4 Grooming washing hands and face brushing teeth combing hair shaving applying makeup 0 Requires total assistance 1 Requires partial assistance 2 Grooms independently with adaptive devices 3 Grooms independently without adaptive devices SUBTOTAL 0 20 SCIM spINAL CORD INDEPENDENCE MEASURE 2 of 3 Respiration and Sphincter Management 5 Respiration 0 Requires tracheal tube TT and permanent or intermittent assisted ventilation IAV 2 Breathes independently with TT requires oxygen much assistance in coughing or TT management 4 Breathes independently with TT requires little assistance in coughing or TT management 6 Breathes independently without TT requires oxygen much assistance in coughing a mask e g peep or IAV bipap 8 Breathes independently without TT requires little assis
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