Survey

Please select one of the answers to each question:

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Patient Full Name*
Date of Birth
MM slash DD slash YYYY
Mobile*
1. Has the result of the Ear operation affected the things you do?*
Much worse
1 A little worse
2 No change
3 A little better
4 Much better
5
2. Has the result of the Ear operation made your overall life better or worse?*
Much better
5 A little better
4 No change
3 A little worse
2 Much worse
1
3. Since your Ear operation, have you felt more or less optimistic about the future?*
Much more optimistic
5 A little more optimistic
4 No change
3 A little less optimistic
2 Much less optimistic
1
4. Since your Ear operation, do you feel more or less embarrassed when with a group of people?*
Much more embarrassed
1 A little more embarrassed
2 No change
3 A little less embarrassed
4 Much less embarrassed
5
5. Since your Ear operation, do you have more or less self-confidence?*
Much more self-confidence
5 A little more self-confidence
4 No change
3 A little less self-confidence
2 Much less self-confidence
1
6. Since your Ear operation, have you found it easier to deal with company?*
Much easier
5 Easier
4 No change
3 Harder
2 Much harder
1
7. Since your Ear operation, do you feel that you have had more or less support from your friends?*
Much more support
5 More support
4 No change
3 Less support
2 Much less support
1
8. Have you been to your general practitioner (GP) for any reason, more or less often, since your Ear operation?*
Much more often
1 More often
2 No change
3 Less often
4 Much less often
5
9. Since your Ear operation, do you feel more or less confident about job opportunities?*
Much more confident
5 More confident
4 No change
3 Less confident
2 Much less confident
1
10. Since your Ear operation, do you feel more or less self-conscious?*
Much more self conscious
1 A little more self-conscious
2 No change
3 A little less self-conscious
4 A little more self-conscious
5
11. Since your Ear operation, are there more or fewer people who really care about you?*
Many more people
5 More people
4 No change
3 Fewer people
2 Much fewer people
1
12. Since your Ear operation, do you catch colds or infections more or less often?*
Much more often
1 More often
2 No change
3 Less often
4 Much less often
5
13. Have you had to take more or less medicine for any reason, since your Ear operation?*
Much more medicine
1 More medicine
2 No change
3 Less medicine
4 Much less medicine
5
14. Since your Ear operation, do you feel better or worse about yourself?*
Much better
5 Better
4 No change
3 Worse
2 Much worse
1
15. Since your Ear operation, do you feel that you have had more or less support from your family?*
Much more support
5 More support
4 No change
3 Less support
2 Much less support
1
16. Since your Ear operation, are you more or less inconvenienced by your ear?*
Much more inconvenienced
1 More inconvenienced
2 No change
3 Less inconvenienced
4 Much less inconvenienced
5
17. Since your Ear operation, have you been able to participate in more or fewer social activities?*
Many more activities
5 More activities
4 No change
3 Fewer activities
2 Much fewer activities
1
18. Since your Ear operation, have you been more or less inclined to withdraw from social situations?*
Much more inclined
1 More inclined
2 No change
3 Less inclined
4 Much less inclined
5