Complete Patient Care evaluation

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How important is it to treat your bowel problems?

Not important	Slightly Important	Moderately important	Very important	Extremely Important
Not importantDo your bowel symptoms bother you Not important	Slightly ImportantDo your bowel symptoms bother you Slightly Important	Moderately importantDo your bowel symptoms bother you Moderately important	Very importantDo your bowel symptoms bother you Very important	Extremely ImportantDo your bowel symptoms bother you Extremely Important

How do you feel about starting rectal irrigation?

Not keen	Slightly keen	Keen	Fairly keen	Very keen
Not keenDo your bowel symptoms bother you Not keen	Slightly keenDo your bowel symptoms bother you Slightly keen	KeenDo your bowel symptoms bother you Keen	Fairly keenDo your bowel symptoms bother you Fairly keen	Very keenDo your bowel symptoms bother you Very keen

How are you?

To be able to assess the progress you are making through your irrigation journey we have a few questions to ask.

3 month Progress check

As you have now been using your Qufora system for 3 months, we wanted to revisit some of the questions we asked at the start of your irrigation journey.

6 month Progress check

As you have now been using your Qufora system for 6 months, we wanted to revisit some of the questions we asked at the start of your irrigation journey.

9 month Progress check

As you have now been using your Qufora system for 9 months, we wanted to revisit some of the questions we asked at the start of your irrigation journey.

overall your to

12 month Progress check

As you have now been using your Qufora system for 12 months, we wanted to revisit some of the questions we asked at the start of your irrigation journey.

Do your bowel symptoms bother you

Not at all	A little bit	Some	Quite a bit	A lot
Not at allDo your bowel symptoms bother you Not at all	A little bitDo your bowel symptoms bother you A little bit	SomeDo your bowel symptoms bother you Some	Quite a bitDo your bowel symptoms bother you Quite a bit	A lotDo your bowel symptoms bother you A lot

Symptom

Please choose a symptom which bothers you the most, and enter in the box below

Now, score how bad it has been over the past week

0	1	2	3	4	5	6
0Patient Goal 0	1Patient Goal 1	2Patient Goal 2	3Patient Goal 3	4Patient Goal 4	5Patient Goal 5	6Patient Goal 6

Where
0 is as good as it can be
6 is as bad as it can be

Activity

Choose an activity (physical, social, mental) that is important to you and that your problem makes difficult or prevents you doing, and enter this in the box below.

Now, score how bad it has been in the last week

0	1	2	3	4	5	6
0Patient Goal 0	1Patient Goal 1	2Patient Goal 2	3Patient Goal 3	4Patient Goal 4	5Patient Goal 5	6Patient Goal 6

Where
0 is as good as it can be
6 is as bad as it can be

How satisfied are you with your overall experience with Qufora?

Extremely dissatisfied	Dissatisfied	Neutral	Satisfied	Extremely satisfied
Extremely dissatisfiedItem #1 Extremely dissatisfied	DissatisfiedItem #1 Dissatisfied	NeutralItem #1 Neutral	SatisfiedItem #1 Satisfied	Extremely satisfiedItem #1 Extremely satisfied

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