Colon Health Survey (Male)

Colon Health Survey (Male)
Kimberly‚ 2009
 
1.    Have you done a stool blood test at home in the last 12 months? Yes‚ No
2.    Have you ever had a sigmoidoscopy or flexible sigmoidoscopy? Yes‚ No
3.    Have you ever had a barium enema? Yes‚ No
4.    Have you ever had a colectomy? Yes‚ No
5.    Have you ever been told you have ulcerative colitis or Crohn’s disease? Yes‚ No
6.    Have you ever had cancer of the colon or rectum? Yes‚ No
7.    What is your highest level of education?
8.    What is your marital status?
9.    What do you consider your race to be?
10.What is your total yearly combined household income?
11.Have you ever had a colonoscopy? Yes‚ No
12.When was your last colonoscopy? Less than 10 years ago‚ More than 10 years ago‚ I have not had a colonoscopy
13.Are you planning to have a colonoscopy in the next 6 months? Yes‚ No
14.Do you have an appointment scheduled for a colonoscopy? Yes‚ No
15.Has a doctor ever recommended that you get a colonoscopy? Yes‚ No
16.Can colon cancer ever be prevented? Yes‚ No‚ Don’t know
17.Who is most likely to get colon cancer?
·         A person younger than 50 years old
·         A person older than 50 years old
·         There is no difference
·         Don’t know
18.Which group is more likely to get colon cancer? Whites‚ Blacks‚ Hispanics‚ There is no difference‚ Don’t know.
19.Who is more likely to get colon cancer?
·         Someone whose spouse had colon cancer
·         Someone with one close blood relative (parent‚ brother‚ or sister) who had colon cancer
·         Someone with two close blood relatives (parent‚ brother‚ or sister) who had colon cancer
·         There is no difference
·         Don’t know
20.Compared to a man‚ what is a woman’s chance of getting colon cancer?
·         Much higher than a man’s
·         About the same as a man’s.
·         Much lower than a man’s.
·         Don’t know
21.What is the most effective way for people to lower their chances of dying from colon cancer?
·         Exercising regularly
·         Limiting alcohol
·         Finding and removing polyps
·         There is nothing that can be done
·         Don’t know
22.What is a doctor able to see during a colonoscopy?
·         Inside only the lower part of the colon
·         Hidden blood in the stool
·         Inside the entire length of the colon
·         Don’t know
23.If you choose to have a colonoscopy and everything is normal‚ when will you probably need to have your next one?
·         6 months.
·         1 year
·         2 years
·         5 years
·         10 years
·         Don’t know
Questions 24-33 are about the steps required to complete a colonoscopy. Please indicate HOW SURE you are that you can complete each step by marking a small X in one box per question.
Not at all sure‚ Not so sure‚ Somewhat sure‚ Very sure
24.I am able to get an appointment to have a colonoscopy.
25.I am able to find time to have a colonoscopy.
26.I am able to drink the special medicine (laxative) to clean out my bowel before a colonoscopy.
27.I am able to go without solid food for a day before the colonoscopy.
28.I am able to find transportation to get to and from the clinic to have a colonoscopy.
29.I am able to get my questions answered about ha‎ving a colonoscopy.
30.I am able to follow instructions to clean out my bowel before a colonoscopy.
31.I am able to get a colonoscopy even if I am worried about the results.
32.I am able to have a colonoscopy even if I don’t know what to expect.
33.I am able to have a colonoscopy even if I am anxious.
Strongly disagree‚ Disagree‚ Agree‚ Strongly agree
34.I worry about finding something wrong during a colonoscopy.
35.ha‎ving a colonoscopy is embarrassing.
36.I don’t have the time to have a colonoscopy.
37.I don’t understand what will be done during a colonoscopy.
38.A colonoscopy could be painful.
39.I would need to have a colonoscopy only if I have bowel problems or symptoms.
40.ha‎ving to find someone to drive me home would be hard.
41.ha‎ving to take the special medicine (laxative) to clean out my bowel before the
42.ha‎ving to limit what I eat before the colonoscopy would be hard.
43.I am afraid that my colon could be injured during a colonoscopy.
44.ha‎ving a colonoscopy is not that important right now.
45.Thinking about ha‎ving a colonoscopy makes me feel nervous or jittery.
46.ha‎ving to see a doctor I don’t know would make it hard to have a colonoscopy.
47.I don’t need a colonoscopy at my age.
For questions 48 and 49‚ please complete the statement by writing in the space provided:
48.For me‚ the most embarrassing part of ha‎ving a colonoscopy would be:
________________________________________________________________________
________________________________________________________________________
49.I would be less embarrassed to have a colonoscopy if:
_______________________________________________________________________
_______________________________________________________________________
Colonoscopy Embarrassment Scale
Strongly disagree‚ Disagree‚ Agree‚ Strongly agree
50.I would be embarrassed to have a colonoscopy if a female did the test.
51.I would be embarrassed to have a colonoscopy if I did not know the doctor doing the test.
52.I would be embarrassed to have a colonoscopy if a medical student or nursing student was in the room to watch.
53.I would be embarrassed to have a colonoscopy if I passed gas during the test.
54.I would be embarrassed to have a colonoscopy if I had to be awake for the test.
55.I would be embarrassed to have a colonoscopy if the doctor joked with me about the test.
56.I would be embarrassed to have a colonoscopy if I had to talk to the doctor or nurse about my bowel movements.
57.I would be embarrassed to have a colonoscopy if I had to talk to my doctor or nurse about problems with my bottom/buttocks.
58.I would be embarrassed to have a colonoscopy because my bowel may not be clean after the bowel prep.
59.I would be embarrassed to have a colonoscopy because of the size or appearance of my bottom/buttocks.
60.I would be embarrassed to have a colonoscopy because someone will be touching my bottom/buttocks.
61.I would be embarrassed to have a colonoscopy because the tube is being put into my rectum.
62.I would be embarrassed to have a colonoscopy because I might smell.
63.I would be embarrassed to have a colonoscopy because of concern that my penis would not be covered during the test.
64.I would be embarrassed to have a colonoscopy because the doctor or nurse will see my bottom/buttocks.
 
This instrument can be found at: Kimberly‚ 2009
 

Kimberly‚ Ann Mitchell (2009). Development and Testing of the Colonoscopy Embarrassment scale. Indiana University‚ PhD dissertation.

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