From: Quality of life and patient satisfaction in bracing treatment of adolescent idiopathic scoliosis
| This questionnaire asks how you feel about your health, while you are wearing a brace. This is not a test and there are no right or wrong answers. | |
| Please read carefully every question | |
| Choose the best answer and mark with an x | |
| Example | |
| • During the last week, you were in a good mood for studying | |
| • Never | |
| • Almost never | |
| • Sometimes | |
| • Most of the times | |
| • Always | |
| Please tell us a few things about yourself: | |
| You are a boy/a girl (cross out what is NOT correct) | |
| How old are you? ......... years. | |
| You are wearing the brace since ………. months/years. | |
| You are wearing the brace for ….. hours/day | |
| Date …………………………… | |
| During the first 3 months | |
| 1. The brace made you feel ill | |
| • Never | |
| • Almost never | |
| • Sometimes | |
| • Most of the time | |
| • Always | |
| 2. You were afraid that your back will get worse | |
| • Never | |
| • Almost never | |
| • Sometimes | |
| • Most of the time | |
| • Always | |
| During the past 3 months while you were wearing the brace... | |
| 3. You felt tired when walking | |
| • Never | |
| • Almost never | |
| • Sometimes | |
| • Most of the time | |
| • Always | |
| 4. You were able to run | |
| • Never | |
| • Almost never | |
| • Sometimes | |
| • Most of the time | |
| • Always | |
| 5. You managed to wear the brace without any help | |
| • Never | |
| • Almost never | |
| • Sometimes | |
| • Most of the time | |
| • Always | |
| 6. You managed to take off the brace without any help | |
| • Never | |
| • Almost never | |
| • Sometimes | |
| • Most of the time | |
| • Always | |
| 7. You could not eat well | |
| • Never | |
| • Almost never | |
| • Sometimes | |
| • Most of the time | |
| • Always | |
| 8. You could not sleep well | |
| • Never | |
| • Almost never | |
| • Sometimes | |
| • Most of the time | |
| • Always | |
| 9. You could not breathe well | |
| • Never | |
| • Almost never | |
| • Sometimes | |
| • Most of the time | |
| • Always | |
| During the past 3 months… | |
| 10. The brace made you feel nervous | |
| • Never | |
| • Almost never | |
| • Sometimes | |
| • Most of the time | |
| • Always | |
| 11. You felt worried because of the brace | |
| • Never | |
| • Almost never | |
| • Sometimes | |
| • Most of the time | |
| • Always | |
| 12. You felt happy | |
| • Never | |
| • Almost never | |
| • Sometimes | |
| • Most of the time | |
| • Always | |
| 13. You believed that your life would be better if you were not on brace | |
| • Never | |
| • Almost never | |
| • Sometimes | |
| • Most of the time | |
| • Always | |
| 14. You believed that brace treatment was beneficial | |
| • Never | |
| • Almost never | |
| • Sometimes | |
| • Most of the time | |
| • Always | |
| During the past 1 month... | |
| 15. You felt proud of yourself | |
| • Never | |
| • Almost never | |
| • Sometimes | |
| • Most of the time | |
| • Always | |
| 16. You were satisfied with your body | |
| • Never | |
| • Almost never | |
| • Sometimes | |
| • Most of the time | |
| • Always | |
| During the past 1 month | |
| 17. You felt strong and full of energy | |
| • Never | |
| • Almost never | |
| • Sometimes | |
| • Most of the time | |
| • Always | |
| 18. You felt tired and exhausted because of the brace | |
| • Never | |
| • Almost never | |
| • Sometimes | |
| • Most of the time | |
| • Always | |
| During the past 1 month, because of the brace... | |
| 19. You had difficulties with your lessons | |
| • Never | |
| • Almost never | |
| • Sometimes | |
| • Most of the time | |
| • Always | |
| 20. You were absent from school | |
| • Never | |
| • Almost never | |
| • Sometimes | |
| • Most of the time | |
| • Always | |
| 21. You found it hard to pay attention in the classroom | |
| • Never | |
| • Almost never | |
| • Sometimes | |
| • Most of the time | |
| • Always | |
| During the past 1 month, while you were wearing the brace... | |
| 22. You had to take medication for pain | |
| • Never | |
| • Almost never | |
| • Sometimes | |
| • Most of the time | |
| • Always | |
| 23. You had pain during the night | |
| • Never | |
| • Almost never | |
| • Sometimes | |
| • Most of the time | |
| • Always | |
| 24. You had pain when walking | |
| • Never | |
| • Almost never | |
| • Sometimes | |
| • Most of the time | |
| • Always | |
| 25. You had pain when sitting | |
| • Never | |
| • Almost never | |
| • Sometimes | |
| • Most of the time | |
| • Always | |
| 26. You had pain when climbing stairs | |
| • Never | |
| • Almost never | |
| • Sometimes | |
| • Most of the time | |
| • Always | |
| 27. You felt pins and needles in your arms or legs | |
| • Never | |
| • Almost never | |
| • Sometimes | |
| • Most of the time | |
| • Always | |
| During the past 1 month, because of the brace... | |
| 28. You could not go out with your friends | |
| • Never | |
| • Almost never | |
| • Sometimes | |
| • Most of the time | |
| • Always | |
| 29. Your friends felt compassion for you | |
| • Never | |
| • Almost never | |
| • Sometimes | |
| • Most of the time | |
| • Always | |
| 30. You felt different from your peers | |
| • Never | |
| • Almost never | |
| • Sometimes | |
| • Most of the time | |
| • Always | |
| 31. You had problems with your family | |
| • Never | |
| • Almost never | |
| • Sometimes | |
| • Most of the time | |
| • Always | |
| 32. You believed that your relationship with your family or your friends would be better if you were not on brace | |
| • Never | |
| • Almost never | |
| • Sometimes | |
| • Most of the time | |
| • Always | |
| 33. You stayed at home because you were ashamed | |
| • Never | |
| • Almost never | |
| • Sometimes | |
| • Most of the time | |
| • Always | |
| 34. You wore special clothes | |
| • Never | |
| • Almost never | |
| • Sometimes | |
| • Most of the time | |
| • Always |