Topic:

Experience of threats to one’s well-being in the medical setting

What:

Study of overwhelming or traumatic emotional experiences produced by medical procedures, treatments, or negative interactions with medical personnel.

Notice:

Participation in study is voluntary and psychological treatment is not involved in the project.
Participants grant permission to use information volunteered for research and publication.
Real names will not be used in any published or publicized materials.
Participants may be contacted for additional information if needed.

 

To participate in the study, please complete the questionnaire that follows:

Was your negative experience in (click on one answer):

a hospital a doctor's office or clinic rehabilitation facility dialysis center other (explain below)

If other please enter here:

Did this experience involve (click on one answer):

non-invasive medical equipment (e.g., MRI, X-ray, CT scan, radiation treatment, etc)
invasive procedures (e.g., endoscopy, colonoscopy, heart catheter, intubation surgery, etc.)
being physically lifted or moved, or being examined or touched
reactions to medications, chemotherapy, anesthesia
negative interactions with medical personnel
other

If other, explain here:

Was the location or environment (click on one answer):

familiar to you
unfamiliar to you

Was there any other major negative medical experience prior to this one?

Yes
No

What symptoms did you have at the time of this experience? (click on all answers that apply):

confused/didn’t understand
embarrassed/ashamed
felt threatened
panic/anxiety/fear
frustration/anger
felt ignored/feelings disregarded
felt punished/blamed
physical pain
thought I might die
helplessness/no control
felt like a child
felt intimidated   
felt used or abused

Since this incident, have you experienced (click on all that apply):

nightmares about  it
intrusive or obsessive thoughts about it
anxiety when exposed to reminders of it
depressed mood
lower self-esteem
difficulty concentrating
sleep problems 
problems with job performance or household
responsibilities
crying jags
irritable mood
significant changes in appetite
social withdrawal or isolation
loss of interest in usual activities
episodes of emotional numbness
episodes of feeling disconnected from yourself or
things around you
episodes of re-experiencing the event as if it were
happening again                                       

Have you sought counseling for symptoms associated with this event?

Yes
No

Have you changed doctors or medical providers or medical facilities because of this experience?

Yes
No

Have you changed healthcare habits or forms of health treatment because of this experience?

Yes
No

Have you ever been diagnosed with any of the following (click on all that apply):

PTSD
Anxiety
Depression
Other mental health problem

In the box below, please describe what happened as briefly as possible:

Contact Information:

First Name
Home Phone	In case we need to ask more questions.
E-mail