1 | To what extent do you feel physically impaired by the implanted device (pacemaker, defibrillator)? |
| □ No impairment | □ Limited impairment | □ Considerable impairment | □ Disabling impairment |
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2 | How often do you think about the implanted device? |
| □ Never | □ Sometimes | □ Several days a week | □ Every day |
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3 | Did you feel depressed when you were informed about the necessity of a device implantation? |
| □ No | □ Yes, to some degree | □ Yes, considerably | □ Yes, very much |
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4 | Since implantation, to what extent are you preoccupied with your heart condition? |
| □ None | □ To some degree | □ Considerably | □ Very much |
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5 | Did the implanted device change your image of your body? |
| □ Yes | □ No | | |
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6 | To what extent do the visible changes at the implantation site disturb you? |
| □ Does not disturb | □ To some degree | □ Considerably | □ Very much |
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7 | Does the implanted device disturb you in daily life? |
| □ No | □ Yes, a little | □ Yes, considerably | □ Yes, very much |
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8 | Does the implanted device disturb you in your leisure activities? |
| □ No | □ Yes, a little | □ Yes, considerably | □ Yes, very much |
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9 | Do you have anxiety about premature battery depletion? |
| □ No | □ Yes, a little | □ Yes, considerably | □ Yes, very much |
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10 | Do you have anxiety about malfunction of the implanted device? |
| □ No | □ Yes, a little | □ Yes, considerably | □ Yes, very much |
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11 | How well are you informed about the implanted device? |
| □ Badly | □ Moderately | □ Well | □ Very well |
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12 | How well are you informed about your heart disease? |
| □ Badly | □ Moderately | □ Well | □ Very well |
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13 | Is the implanted device a source of security for you? |
| □ No | □ A little | □ Considerably | □ Very much |
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14 | Is the implanted device a life extender for you? |
| □ No | □ A little | □ Considerably | □ Very much |
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15 | Is the implanted device a source of anxiety for you? |
| □ No | □ A little | □ Considerably | □ Very much |
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16 | Would you rather have more frequent appointments with your physician? |
| □ Yes | □ No | | |
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17 | Would you rather have longer appointments with your physician? |
| □ Yes | □ No | | |
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18 | Would you also consider having psychological or psychotherapeutic support? |
| □ Yes | □ No | | |
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19 | Would you also consider being involved in a support group? |
| □ Yes | □ No | | |
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20 | Do you believe that the public should be better informed about the implantable devices for heart diseases? |
| □ Yes | □ No | | |
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21 | How do you feel now as compared to your status before the implantation? |
| □ Worse | □ Same | □ Better | |
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22 | How long did it take you to adjust the implanted device? |
| □ Less than 1 month | □ Up to 6 months | □ Up to 1 year | □ Up to 2 years | □ Not yet |
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23 | Overall, was it worthwhile having the device implanted? |
| □ No | □ Probably | □ Yes | |