Questionnaire for the Bachelor’s Thesis

Dear respondents,

My name is Martina Kroupová, and I am a third-year student of Radiological Assistance at the University of South Bohemia in České Budějovice. I am reaching out to you with a request to fill out my questionnaire, which will serve as a basis for my bachelor’s thesis on the topic “Adverse Effects of Radiotherapy in Curatively Treated Patients with Colorectal Cancer.”

The questionnaire is completely anonymous, so please do not provide your name. The results of this questionnaire survey will be used solely for my bachelor’s thesis.

Thank you.


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Questionnaire for my Bachelor’s Thesis
1

What is your gender?

2

How old are you?

3

What was your approximate date of completion of radiotherapy?

4

Did you undergo a surgical procedure prior to radiotherapy?

Select one answer
5

During the treatment, did you receive any other form of therapy (e.g., chemotherapy)?

Vyberte jednu odpověď
6

During the treatment, did you receive any other form of therapy (e.g., chemotherapy)? If yes, which?

Acute Adverse Effects (during radiotherapy or shortly afterward)

Did you experience the following problems during treatment?

If Yes, choose how severe these problems were (1 star = very mild, 5 star = very severe).

If No, leave it blank.

7

Diarrhea

8

Nausea

9

Vomiting

10

Bloating

11

Pain in the pelvic area or around the rectum

12

Fatigue or weakness

13

Redness in the Irradiated Area

14

Itching in the Irradiated Area

15

Frequent urination

16

Blood in urine

17

Did you have sleep problems?

18

Other problems (please specify)

19

Were these problems manageable with medications or other measures during treatment?

20

Did you have to interrupt the treatment due to acute adverse effects?

Late Adverse Effects (months to years after treatment)

Have you experienced the following problems? If Yes, choose how severe they were (1 star = very mild, 5 star = very severe).

21

Chronic (long-term) diarrhea

22

Constipation

23

Blood in stool

24

Fecal incontinence

25

Frequent urination

26

Pain during urination

27

Urinary incontinence

28

Pain in the pelvic area or around the rectum

29

Swelling of the lower limbs

30

Scarring in the Irradiated Area

31

Sensitivity in the Irradiated Area

32

Dryness in the Irradiated Area

33

Sexual Dysfunction

34

Fatigue or Weakness

35

Depression

36

Anxiety

37

Other problems (please specify)

38

Do you notice any change in your quality of life after the treatment?

1 star = no changes to 5 star = significant deterioration
39

Do you feel that the treatment was sufficiently explained and that you were informed about possible risks?

1 star = not informed at all to 5 star = fully informed
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