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POLICY AND CONSENT MANIFESTATIONTO THE PERSONAL DATA TREATMENT in accordance with article 13 of Regulation no. 2016/679 / EU and the current national privacy policy (Personal Data Protection Code)

Dear user,

in accordance with article 13 of the Privacy Code and article 14 of EU Regulation no. 679/2016 (below the EU Regulation) through this we provide you with information about the procedures and purposes of processing your data collected through our registry.

 

1. Data controller and data protection officer

The Group of Relative Betasarcoglycanopathies ETS (GFB ETS) and the Stem Cell Laboratory, led by Dr. Yvan Torrente, have promoted the described study, each one for its area of ​​competence and, in accordance with the responsibilities under standards of good clinical practice (DL 211/2003), will process your Personal Data, especially your health and medical history and other sensitive data, solely for the registration and implementation of the Quality Project.

 

The processing of your personal data is essential for carrying out the Study; any refusal will not allow you to participate in the trial.

 

You can contact the Data Protection Officer by sending an email to: volbeat@libero.it

VOLA BEATRICE GFB ETS President

 

2. Data processing

a) Personal Data: Personal Data, such as name, date of birth, gender and place of residence, are collected and stored separately from the clinical data stored in the registry or from the quality of life data collected in the Quality Project. . These dara are never expressed in the registry/Quality Project, but are replaced by automatically created pseudonyms so that they cannot be traced back to the patient's identity. With the exception of the persons mentioned in section 4, no user of the registry / Quality Project will be able to link the identity of the patient to the data collected and recorded in the registry / project.

b) Data related to the registry: the registry will collect different clinical data related to its pathology and its evolution. For more information, see the third part of this document "Patient Information".

c) Data of the Quality Project: the project will collect the data of the questionnaires that will be administered.

d) Data on biological samples: the registry also contains information on the biological samples collected, especially on the muscle biopsies performed, type, date of collection and immunohistochemical characteristics.

The doctor who will follow you during the trial will ensure your anonymity, treating your common and personal data differently from identification data (personal data) so that it is not possible to associate them with your person,

 

transforming them anonymously. For this reason, the study director will give you, at the beginning of the study, a code to be identified during the following stages of the study itself. Your data, the important ones for the study, except your name, will be registered, processed and stored together with that code and with all the clinical data related to your health. Only the doctor and authorized persons will be able to match this code with your name.

 

3. Purpose of treatment

Personal data and data that may reveal genetic information, provided by you or collected by authorized third parties, are collected and processed for the following purposes:

• Prevention of certain diseases;

• Healing and therapy of the relatives of the interested party;

• Therapy or prevention programs (trial);

• Diagnosis of genetic diseases (diagnostic test);

• Diagnosis of pathologies described in the national registry of rare diseases;

• Prenatal diagnosis;

• Genetic screening;

• Prevention of genetic pathology in high-risk populations;

• Prevention of pathologies described in the national and/or regional registry of rare diseases;

• Statistical, medical and biomedical research;

• Trial of drugs for clinical use;

• Studies on the human genome;

• Transplantation of organs and tissues.

 

The confidential data provided may be processed in other registries for the purpose of assisted procreation, electronic provision of health services in relation to the database or supply of goods, epidemiological investigations, detection of mental, infectious and disseminated diseases, organ transplants and tissues and monitoring of health spending. .

 

4. Processing methods

Personal data is processed by the Data Controller in accordance with the principles of legality, correctness and transparency.

The processing of your personal data is carried out through the following operations: collection, registration, organization, structure, storage, consultation, adaptation or modification of datas, use, dissemination, communication, extraction, comparison, interconnection, restriction, suppression and destruction.

Your data will be processed by computer and non-computer tools and will be stored in paper files at the GFB ETS site and electronic databases and will be disseminated strictly anonymously, for example through scientific journals, statistics and scientific conferences.

The data controller will process personal data which will be stored for the period necessary for the purpose of the processing and then deleted, unless further requested.

The interested parties will not be identified during the registration query and their personal data will be protected by a cryptographic system. Identification is authorized only to the LGMD 2C-2D-2E registry and Quality Project Manager and to those in charge of informing the user following the need for processing.

 

5. Access to data

Your data may be made accessible, for the purposes specified in article 2, to the following recipients:

• You, at any time you wish, can access information about you that is in the Quality registry/project by contacting the doctor who has included you in the Quality registry/project. In addition, your doctor could explain the meaning of the recorded data, in case of doubt.

• Your doctor and his team will have access to your clinical data.

• Doctors of the Dino Ferrari Center: the data stored in the registry could be accessible to researchers and doctors for scientific studies. Any data that may be exported will be given a new pseudonym and cannot be linked to your identity.

• Second opinion: the personal data (or part of it) of a specific person may be transmitted in special cases for a special purpose. The data will be transmitted only temporarily.

• Researchers (only after a precise evaluation of the request for access to the LGMD 2C-2D-2E / Quality Project scientific registry): if researchers from other institutes request a consultation of the LGMD 2C-2D-2E / Quality Project registry in Para find suitable patients for specific clinical studies, the scientific committee of the Registry / Quality Project will decide whether or not to allow access to the data and its transmission. Here too, the possibly transmitted data will be anonymised again and thus cannot be traced back to the identity of the patient. In addition, your data may be transmitted anonymously to companies or third parties (Sponsors / Promoters of clinical studies or external companies acting on their behalf also in Countries outside the European Union, even if in joint projects with individuals, public entities ( local, national and international level) research organizations or companies, associations, foundations, non-profit organizations or associations, clinical laboratories, National Health Service organizations, doctors and medical personnel, pharmaceutical companies) that carry out a research activity that require access to the registry.

• Administrator: the data collected in the registry / Quality project will be visible to the administrator of the computing resources used for the registry. This will happen only if a task needs to be completed and will be logged.

• Public entities: for the fulfillment of legal obligations, and before the judicial authority, in case of formal request. The Ethics Committee and the Italian and foreign Health Authorities may see your data, collected in your original medical documents, solely to verify the procedures of the Study and the accuracy and correctness of the data collected, taking all necessary precautions to guarantee its confidentiality, identity and within the limits of the applicable regulations, with special respect to the principles of correctness, accuracy, relevance and integrity of the treatment (art.11 D.Lgs. 196/2003 - Personal Data Protection Code).

 

All authorized parties are required to keep the information confidential. All data publication will be anonymous.

The full list of all third-party controllers, who were able to see your Data while working with the Controller, is located on the foundation seat and can be viewed on request.

 

6. Rights of the interested party

Pursuant to and for the purposes of article 13 of Regulation no. 2016/679 / EU and current national legislation on privacy. You have the right to obtain: access to personal data, suggestions on the forms, purposes and approaches of treatment and the request for data restrictions, oppositions or portability, correction and deletion, in accordance with the limits and customs of the Regulation. You have the right to object to the processing of your personal data, in whole or in part, for legitimate reasons.

At any time, you can stop participating in the Study, without providing a justification. No further data about you will be collected and only the collected data will be used, without altering it for the purpose of the research.

 

You have the right to file a claim with the competent authority referred to in article 77 of the Regulations.

 

You can exercise the aforementioned rights and the right to withdraw consent by writing to the Controller Mrs. VOLA BEATRICE President Gruppo Familiari Beta-sarcoglicanopatie ETS, at the email address volbeat@libero.it


EXPRESSION OF CONSENT


Having read the aforementioned information and having understood it in its entirety, by subscribing to this document I accept the processing of my personal data and the transfer outside the European Union for research purposes within the limits and modalities mentioned.


Name and surnames of the subject *
Name and surname of the data controller (to be completed by GFB ETS)
Date *

I, the undersigned, confirm that I have correctly and completely informed the person participating in the Study about the Nature, Objectives and Methods of processing their personal data and, in good conscience, I believe that they have been fully understood . I also confirm that the consent has been freely given.

 

In addition, I also confirm that my consent has been freely released by the subject and that this policy will be stored at the legal headquarters of the Gruppo Familiari Beta-sarcoglicanopatie ETS, in accordance with current regulations and a copy will be delivered to the subject who takes part in the study.

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MOTION LIMITATION EVALUATION QUESTIONNAIRE

INSTRUCTIONS FOR THE ACTIVLIM AND THE ABILHAND QUESTIONNAIRE

 

For a child evaluation (between 6 and 15 years-old):

The parents fill in the questionnaire by estimating their child’s difficulty or ease in performing each activity.

 

For an adult evaluation (more than 16 years-old):

The patient fills in himself the questionnaire by estimating their own difficulty or ease in performing each activity.

 

The activities should be done:

• Without technical or human help (even if the patient actually uses help in daily life)

• Irrespective the limb(s) actually used to achieve the activity

• Whatever the strategy used (any compensation is allowed)

 

Three responses are presented. These assess the perception of the difficulty/ease depending on whether the activity is “impossible”, “difficult” or “easy”. Activities not attempted in the last 3 months are not scored and entered as missing responses (to tick the question mark).

So, for any activity, the four potential answers are:

• Impossible: The patient is unable to perform the activity without using any other help.

• Difficult: The patient is able to perform the activity without any help but experiences some

difficulty.

• Easy: The patient is able to perform the activity without any help and experiences no

difficulty.

• Question mark: The patient cannot estimate the difficulty of the activity because he has never done the activity.

 

Watch out!! If the activity was never attempted because it is impossible, then it must be scored “impossible” rather than “question mark”.

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Name and surname *
Age *
Email *
Date of birth *
Height *
Number *
+39
Ricerca
    Address *
    Diagnosis / Name of the disease *
    Weight *
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    ACTIVLIM - Activity Limitations Measure

    ACTIVLIM © UCL 2007 - all rights reserved

    1 - Putting on a T-Shirt
    2 - Washing one's upper body
    3 - Dressing one's lower body
    4 - Taking a shower
    5 - Sitting on the toilet
    6 - Taking a bath
    7 - Walking downstairs
    8 - Stepping out of a bath tub
    9 - Opening a door
    10 - Walking outdoors on level ground
    11 - Washing one's face
    12 - Hanging up a jacket on a handstand
    13 - Wiping one's upper body
    14 - Walking upstairs

    To evaluate an adult patient (age 16-80), please answer to the following question.

    15 - Carrying a heavy load
    16 - Getting into a car
    17 - Standing for a long time (+10 min)
    18 - Walking more than a kilometer

    To evaluate a child patient (age 6-15), please answer to the following question.

    19 - Closing a door
    20 - Hopping on one foot
    21 - Putting on a backpack
    22 - Running
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    ABILHAND – Manual Ability Measure

    ABILHAND © UCL 2010 - all rights reserved

    1 - Wiping one's hand
    2 - Spreading butter on a slice of bread
    3 - Turning a key in a keyhole
    4 - Fastening a snap (jacket, bag...)
    5 - Squeezing toothpaste onto a toothbrush
    6 - Filling glass with water
    7 - Opening a bread box
    8 - Turning on a tap
    9 - Washing one's hands
    10 - Opening a toothpaste tube
    11 - Opening a pack of biscuits
    12 - Buttoning up a shirt
    13 - Turning off a tap
    14 - Fastening zipper of a jacket

    To evaluate an adult patient (age 16-80), please answer the following question

    15 - Taking the cap off a bottle
    16 - Cutting one's nails
    17 - Inserting a key in a keyhole
    18 - Counting banknotes

    To evaluate a child patient (age 6-15), please answer the following question

    19 - Opening a pack of chips
    20 - Sharpening a pencil
    21 - Dealing cards
    22 - Unwrapping a chocolate bar
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    EK SCALE

    1 - Ability to use wheelchair - How do you get around indoors and outdoors?
    Able to use a manual wheelchair on flat ground, 10m < 1 minute
    Able to use a manual wheelchair on flat ground, 10m > 1 minute
    Unable to use manual wheelchair, requires power wheelchair
    Uses power wheelchair, but occasionally has difficulty steering
    2 - Ability to transfer from wheelchair
    Able to transfer from wheelchair without help
    Able to transfer indipendently from wheelchair, with use of aid
    Needs assistance to transfer with or without additional aids (hoits, easy glide)
    Needs to be lifted with support of head when transferring from wheelchair
    3 - Ability to stand
    Able to stand with knees supported
    Able to stand with knees and hips supported, as when using standing aids
    Able to stand with full body support
    Unable to be stood
    4 - Ability to balance wheelchair
    Able to push himself upright from complete forward flexion by pushing up with hands
    Able to move the upper part of the body >= 30 in all directions from the upright position, but cannot push himself upright as above
    Able to move the upper part of the body < 30 from one side to the other
    Unable to change position of the upper part of the body, cannot sit without total support of the trunk and head
    5 - Ability to move the arms - Can you move your fingers, hands and arms against gravity?
    Able to raise the arms above the head with or without compensatory movements
    Unable to lift the arms above the head, but able to raise the forearms against gravity, ie. hand to mouth with / without elbow support
    Unable to lift the forearms against gravity, but able to use the hands against gravity when forearm is supported
    Unable to move the hands against gravity but able to use the fingers
    6 - Ability to use the hands and arms for eating - Can you describe how you eat and drink?
    Able to eat and drink without elbow support
    Eats of drinks with support at elbow
    Eats and drinks with elbow support; with reinforcement of the opposite hand +or - aids
    Has to be fed
    I have the meat cut and then eat by myself. I fill the glass with 100ml and not with 250ml and take it to my mouth by myself
    7 - Ability to turn in bed - how do you turn in bed during the night?
    Able to turn himself in bed with bedclothes
    I can move on the sofa, but not in the bed
    Unable to turn himself in bed. Has to be turned 0 - 3 times during the night
    Unable to turn himself in bed. Has to be turned >= 4 times during the night
    I turn left alone, right no
    8 - Ability to cough - How do you cough when you have to?
    Able to cough effectively
    Has difficulty to cough and sometimes needs manual reinforcement. Able to clear throat
    Always needs help with coughing. Only possibile to cough in certain positions and with manual reinforcement,air-stacking etc.
    Unable to cough, Needs suction and/or hyperventilation techniques or IPPB in order to keep airways clear
    9 - Ability to speak - Can you speak so that what you say can be understood if you sit at the back of a large room?
    Powerful speech. Able to sing and speak loudly
    Speaks normally, but cannot raise his voice
    Speaks with quiet voice and needs a breath after 3 to 5 words
    Speech is difficult to understand except to close relatives
    10 - Physical well-being - This relates to respiratory insufficiency only (see manual) Use the categories as questions
    No complaints, feels good
    Easily tires. Has difficulty resting in a chair or in bed
    Has loss of weight, loss of appetite, Scared of falling aspleet at night, sleeps badly
    Experience additional symptoms to score 2: change of mood, stomac ache, palpitations, perspiring
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    PedsQL

    All LGMD2C / R5 2E / R4 2D / R3 patients must complete the PedsQL Duchenne Dystrophy questionnaire.

    The Quality project also uses this questionnaire for LGMDs.

    Each patients must complete two section: one for the patient and one for the family member / companion / caregiver.

    PedsQL 3.0 (18-25) Not to be reproduced without permission Copyright © 1998 JW Varni, Ph.D. All rights reserved

    4/17/2012

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    PedsQL

    Insert Your Age and click "Next" to be redirected to the right section *

    PedsQL 3.0 (18-25) Not to be reproduced without permission Copyright © 1998 JW Varni, Ph.D. All rights reserved

    4/17/2012

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    PedsQL

    Version 3.0

    YOUNG ADULT REPORT (ages 18-25)

     

    DIRECTIONS

    Young Adults with Duchenne Muscular Dystrophy sometimes have special problems. Please tell us how much of a problem each one has been for you during the past ONE month by circling:

    0 if it is never a problem

    1 if it is almost never a problem

    2 if it is sometimes a problem

    3 if it is often a problem

    4 if it is almost always a problem

    There are no right or wrong answers.

    If you do not understand a question, please ask for help.

    PedsQL 3.0 (18-25) Not to be reproduced without permission Copyright © 1998 JW Varni, Ph.D. All rights reserved

    4/17/2012

    1 - I have trouble eating with a fork and knife
    2 - It is hard to write or draw with a pen or pencil
    3 - It is hard to put on my clothes
    4 - It is hard to use the toilet without help
    5 - I need more time than others to complete tasks
    6 - It is hard to take medicines
    7 - My physical therapy or daily stretching hurts
    8 - It is hard to be responsible for my medicines or physical therapy
    9 - It is hard to manage my muscle problem
    10 - I worry about my muscle problem
    11 - I worry whether or not my medicines are working
    12 - I worry about my family
    13 - I worry about needing help from others
    14 - I worry about not being accepted by others
    15 - I worry about being treated differently from others my age
    16 - It is hard for me to tell the doctors and nurses how i feel
    17 - It is hard for me to ask the doctors and nurses questions
    18 - It is hard for me to explain my muscle problem to other people
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    PedsQL

    Version 3.0

    PARENT REPORT for YOUNG ADULTS (ages 18-25)

     

    DIRECTIONS

    Young Adults with Duchenne Muscular Dystrophy sometimes have special problems. Please tell us how much of a problem each one has been for you during the past ONE month by circling:

    0 if it is never a problem

    1 if it is almost never a problem

    2 if it is sometimes a problem

    3 if it is often a problem

    4 if it is almost always a problem

    There are no right or wrong answers.

    If you do not understand a question, please ask for help.

    PedsQL 3.0 (18-25) Not to be reproduced without permission Copyright © 1998 JW Varni, Ph.D. All rights reserved

    4/17/2012

    1 - Trouble eating with a fork and knife
    2 - Difficulty writing or drawing with a pen or pencil
    3 - Difficulty putting his/her clothes on
    4 - Using the toilet without assistance
    5 - Needing more time to complete tasks
    6 - Taking medicines
    7 - Physical therapy or daily exercise causing pain
    8 - Difficulty being responsible for medicines or physical therapy
    9 - Difficulty managing his or her muscle problem
    10 - Worrying about his or her muscle problem
    11 - Worrying about whether or not medicines are working
    12 - Worrying about his or her family
    13 - Worrying about needing help from others
    14 - Worrying about not being accepted by others
    15 - Worrying about being treated differently than others his/her age
    16 - Difficulty telling the doctors and nurses how he/she feels
    17 - Difficulty asking the doctors and nurses questions
    18 - Difficulty explaining his/her muscle problem to other people
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    Mobility Questionnaire

    ADULT REPORT (age > 18)

     

    Please mark one response for each question or statement.

    If you do not understand a question, please ask for help.

    1 - Are you able to stand for one hour?
    2 - Are you able to stand up from an armless straight chair?
    3 - Are you able to run or jog for two miles (3 km)?
    4 - Are you able to go up and down stairs at a normal pace?
    5 - Are you able to go for a walk of at least 15 minutes?
    6 - Are you able to step up and down curbs?
    7 - Are you able to stand with your knees straight?
    8 - Are you able to climb up five steps?
    9 - Are you able to stand up on tiptoes?
    10 - Are you able to jump up and down?
    11 - Are you able to run 100 yards (100 m)?
    12 - Are you able to kneel on the floor?
    13 - Are you able to jump over an object that is 1 foot (30 cm) tall? 
    14 - Are you able to walk in a straight line putting one foot in front of the other (heel to toe) for 5 yards (5 m)?
    15 - Are you able to stand on one foot with your eyes closed for 30 seconds?
    16 - Does your health now limit you in walking about the house?
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    Fatigue Questionnaire

    ADULT REPORT (age > 18)

     

    Please mark one response for each question or statement.

    If you do not understand a question, please ask for help.

    During the past 7 days...

    1 - I feel fatigued
    2 - I feel weak all over
    3 - I feel listless ("washed out")
    4 - I feel tired
    5 - I have trouble starting things because I am tired
    6 - I have trouble finishing things because I am tired
    7 - I have energy
    8 - I am able to do my usual activities
    9 - I need to sleep during the day
    10 - I am too tired to eat
    11 - I need help doing my usual activities
    12 - I am frustrated by being too tired to do the things I want to do
    13 - I have to limit my social activity because I am tired
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    Upper Extremity Questionnaire

    ADULT REPORT (age > 18)

     

    Please mark one response for each question or statement.

    If you do not understand a question, please ask for help.

    1 - Are you able to carry a heavy object (over 10 pounds /5 kg)?
    2 - Are you able to wash your back?
    3 - Are you able to put on and take off a coat or jacket?
    4 - Are you able to carry a shopping bag or briefcase?
    5 - Are you able to lift 10 pounds (5 kg) above your shoulder?
    6 - Are you able to change a light bulb overhead?
    7 - Are you able to pass a 20-pound (10 kg) turkey or ham to other people at the table?
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    Sleep Disturbance Questionnaire

    ADULT REPORT (age > 18)

     

    Please mark one response for each question or statement.

    If you do not understand a question, please ask for help.

    In the past 7 days...

    1 - My sleep quality was

    In the past 7 days...

    2 - My sleep was refreshing
    3 - I had a problem with my sleep
    4 - I had difficulty falling asleep
    5 - My sleep was restless
    6 - I tried hard to get to sleep
    7 - I worried about not being able to fall asleep
    8 - I was satisfied with my sleep
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    Positive Affect Questionnaire

    ADULT REPORT (age > 18)

     

    Please mark one response for each question or statement.

    If you do not understand a question, please ask for help.

    In the past 7 days...

    1 - I felt cheerful
    2 - I felt attentive
    3 - I felt delighted
    4 - I felt happy
    5 - I felt joyful
    6 - I felt enthusiastic
    7 - I felt determined
    8 - I felt interested
    9 - I was thinking creatively
    10 - I liked myself
    11 - I felt peaceful
    12 - I felt good-natured
    13 -I felt useful
    14 - I felt understood
    15 - I felt content
    I finish my questionnaire
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    PedsQL

    Version 3.0

    TEEN REPORT (ages 13-18)

     

    DIRECTIONS

    Young Adults with Duchenne Muscular Dystrophy sometimes have special problems. Please tell us how much of a problem each one has been for you during the past ONE month by circling:

    0 if it is never a problem

    1 if it is almost never a problem

    2 if it is sometimes a problem

    3 if it is often a problem

    4 if it is almost always a problem

    There are no right or wrong answers.

    If you do not understand a question, please ask for help.

    PedsQL 3.0 (18-25) Not to be reproduced without permission Copyright © 1998 JW Varni, Ph.D. All rights reserved

    4/17/2012

    1 - I have trouble eating with a fork and knife
    2 - It is hard to write or draw with a pen or pencil
    3 - It is hard to put on my clothes
    4 - It is hard to use the toilet without help
    5 - I need more time than others to complete tasks
    6 - It is hard to take medicines
    7 - My physical therapy or daily stretching hurts
    8 - It is hard to be responsible for my medicines or physical therapy
    9 - It is hard to manage my muscle problem
    10 - I worry about my muscle problem
    11 - I worry whether or not my medicines are working
     12 - I worry about my family 
    13 - I worry about needing help from others
    14 - I worry about not being accepted by others
    15 - I worry about being treated differently from others my age
    16 - It is hard for me to tell the doctors and nurses how i feel
    17 - It is hard for me to ask the doctors and nurses questions
    18 - It is hard for me to explain my muscle problem to other people
    Indietro Procedi Salva progressi

    PedsQL

    Version 3.0

    PARENT REPORT for TEENS (ages 13-18)

     

    DIRECTIONS

    Young Adults with Duchenne Muscular Dystrophy sometimes have special problems. Please tell us how much of a problem each one has been for you during the past ONE month by circling:

    0 if it is never a problem

    1 if it is almost never a problem

    2 if it is sometimes a problem

    3 if it is often a problem

    4 if it is almost always a problem

    There are no right or wrong answers.

    If you do not understand a question, please ask for help.

    PedsQL 3.0 (18-25) Not to be reproduced without permission Copyright © 1998 JW Varni, Ph.D. All rights reserved

    4/17/2012

    1 - Trouble eating with a fork and knife
    2 - Difficulty writing or drawing with a pen or pencil
    3 - Difficulty putting his/her clothes on
    4 - Using the toilet without assistance
    5 - Needing more time to complete tasks
    6 - Taking medicines
    7 - Physical therapy or daily exercise causing pain
    8 - Difficulty being responsible for medicines or physical therapy
    9 - Difficulty managing his or her muscle problem
    10 - Worrying about his or her muscle problem
    11 - Worrying about whether or not medicines are working
    12 - Worrying about his or her family
    13 - Worrying about needing help from others
    14 - Worrying about not being accepted from others
    15 - Worrying about being treated differently than others his/her age
    16 - Difficulty telling the doctors and nurses how he/she feels
    17 - Difficulty asking the doctors and nurses questions
    18 - Difficulty explaining his/her muscle problem to other people
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    PROMIS

    Proxy Mobility Module

    PROMIS is composed of SIX questionnaires: each of them is divided into TWO pages. 

    The first page must be completed by the CHILD (with the help of the parent) and the following page must be completed by the PARENT.

    Insert Your Age and click "Next" to be redirected to the right section  *

    PROMIS. Not to be reproduced without permission Copyright © 

    Indietro Procedi Salva progressi

    PedsQL

    Version 3.0

    CHILD REPORT (ages 8-12)

     

    DIRECTIONS

    Young Adults with Duchenne Muscular Dystrophy sometimes have special problems. Please tell us how much of a problem each one has been for you during the past ONE month by circling:

    0 if it is never a problem

    1 if it is almost never a problem

    2 if it is sometimes a problem

    3 if it is often a problem

    4 if it is almost always a problem

    There are no right or wrong answers.

    If you do not understand a question, please ask for help.

    PedsQL 3.0 (18-25) Not to be reproduced without permission Copyright © 1998 JW Varni, Ph.D. All rights reserved

    4/17/2012

    1 - I have trouble eating with a fork and knife
    2 - It is hard to write or draw with a pen or pencil
    3 - It is hard to put on my clothes
    4 - It is hard to use the toilet without help
    5 - I need more time than others to complete tasks
    6 - It is hard to take medicines
    7 - My physical therapy or daily stretching hurts
    8 - It is hard to be responsible for my medicines or physical therapy
    9 - It is hard to manage my muscle problem
    10 - I worry about my muscle problem
    11 - I worry whether or not my medicines are working
    12 - I worry about my family
    13 - I worry about needing help from others
    14 - I worry about not being accepted by others
    15 - I worry about being treated differently from others my age
    16 - It is hard for me to tell the doctors and nurses how i feel
    17 - It is hard for me to ask the doctors and nurses questions
    18 - It is hard for me to explain my muscle problem to other people
    Indietro Procedi Salva progressi

    PedsQL

    Version 3.0

    PARENT REPORT for CHILDREN (ages 8-12)

     

    DIRECTIONS

    Young Adults with Duchenne Muscular Dystrophy sometimes have special problems. Please tell us how much of a problem each one has been for you during the past ONE month by circling:

    0 if it is never a problem

    1 if it is almost never a problem

    2 if it is sometimes a problem

    3 if it is often a problem

    4 if it is almost always a problem

    There are no right or wrong answers.

    If you do not understand a question, please ask for help.

    PedsQL 3.0 (18-25) Not to be reproduced without permission Copyright © 1998 JW Varni, Ph.D. All rights reserved

    4/17/2012

    1 - Trouble eating with a fork and knife
    2 - Difficulty writing or drawing with a pen or pencil
    3 - Difficulty putting his/her clothes on
    4 - Using the toilet without assistance
    5 - Needing more time to complete tasks
    6 - Taking medicines
    7 - Physical therapy or daily exercise causing pain
    8 - Difficulty being responsible for medicines or physical therapy
    9 - Difficulty managing his or her muscle problem
    10 - Worrying about his or her muscle problem
    11 - Worrying about whether or not medicines are working
    12 - Worrying about his or her family
    13 - Worrying about needing help from others
    14 - Worrying about not being accepted by others
    15 - Worrying about being treated differently than others his/her age
    16 - Difficulty telling the doctors and nurses how he/she feels
    17 - Difficulty asking the doctors and nurses questions
    18 - Difficulty explaining his/her muscle problem to other people
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    PROMIS

    Proxy Mobility Module

    PROMIS is composed of SIX questionnaires: each of them is divided into TWO pages. 

    The first page must be completed by the CHILD (with the help of the parent) and the following page must be completed by the PARENT.

    Insert Your Age and click "Next" to be redirected to the right section  *

    PROMIS. Not to be reproduced without permission Copyright © 

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    PedsQL

    Version 3.0

    PARENT REPORT for YOUNG CHILDREN (ages 5-7)

     

    DIRECTIONS

    Young Adults with Duchenne Muscular Dystrophy sometimes have special problems. Please tell us how much of a problem each one has been for you during the past ONE month by circling:

    0 if it is never a problem

    1 if it is almost never a problem

    2 if it is sometimes a problem

    3 if it is often a problem

    4 if it is almost always a problem

    There are no right or wrong answers.

    If you do not understand a question, please ask for help.

    PedsQL 3.0 (18-25) Not to be reproduced without permission Copyright © 1998 JW Varni, Ph.D. All rights reserved

    4/17/2012

    1 - Trouble eating with a fork and knife
    2 - Difficulty wiritng or drawing with a pen or pencil
    3 - Difficulty putting his/her clothes on
    4 - Using the toilet without assistance
    5 - Needing more time to complete tasks
    6 - Taking medicines
    7 - Physical therapy or daily exercise causing pain
    8 - Difficulty being responsible for medicines or physical therapy
    9 - Difficulty managing his or her muscle problem
    10 - Worrying about his or her muscle problem
    11 - Worrying about whether or not medicines are working
    12 - Worrying about his or her family
    13 - Worrying about needing help from others
    14 - Worrying about not being accepted by others
    15 - Worrying about being treated differently than others his/her age
    16 - Difficulty telling the doctors and nurses how he/she feels
    17 - Difficulty asking the doctors and nurses questions
    18 - Difficulty explaining his/her muscle problem to other people
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    PROMIS

    Proxy Mobility Module

    PROMIS is composed of SIX questionnaires: each of them is divided into TWO pages. 

    The first page must be completed by the CHILD (with the help of the parent) and the following page must be completed by the PARENT.

    Insert Your Age and click "Next" to be redirected to the right section *

    PROMIS. Not to be reproduced without permission Copyright ©

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    Pediatric Mobility Questionnaire

    YOUNG CHILDREN REPORT (age < 18)

     

    Please mark one response for each question or statement.

    If you do not understand a question, please ask for help.

    In the past 7 days...

    1 - I could do sports and exercise that other kids my age could do
    2 - I could get up from the floor
    3 - I could move my legs
    4 - I could stand up by myself
    5 - I could stand up on my tiptoes
    6 - I could walk up stairs without holding on to anything
    7 - I could ride a bike
    8 - I could walk more than one block
    9 - I could walk across the room
    10 - I could get out of bed by myself
    11 - I could get down on my knees without holding on to something
    12 - I could carry my books in my backpack
    13 - I could go up one step
    14 - I could run a mile

    In the past 7 days...

    15 - I used a wheelchair to get around
    16 - I used a walker, cane or crutches to get around
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    Parent Mobility Questionnaire

    PARENT REPORT for YOUNG CHILDREN (age < 18)

     

    Please mark one response for each question or statement.

    If you do not understand a question, please ask for help.

    In the past 7 days...

    1 - My child could get into bed by himself/herself
    2 - My child could walk across the room
    3 - My child could get in and out of a car
    4 - My child could get up from the floor
    5 - My child could stand up without help
    6 - My child could do sports and exercise that other kids his/her age could do
    7 - My child could walk more than one block
    8 - My child could get up from a regular toilet
    9 - My child could get down on his/her knees without holding on to something
    10 - My child could move his/her legs
    11 - My child could keep up when he/she played with other kids
    12 - My child could ride a bike
    13 - My child could carry his/her books in a backpack
    14 - My child has been physically able to do the activities he/she enjoys most

    In the past 7 days...

    15 - My child used a wheelchair to get around
    16 - My child used a walker, cane or crutches to get around
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    Pediatric Fatigue Questionnaire

    YOUNG CHILDREN REPORT (age < 18)

     

    Please mark one response for each question or statement.

    If you do not understand a question, please ask for help.

    In the past 7 days...

    1 - Being tired made it hard for me to keep up with my schoolwork
    2 - Being tired made it hard for me to play or go out with my friends as much as I'd like
    3 - I felt weak
    4 - I got tired easily
    5 - I had trouble finishing things because I was too tired
    6 - I had trouble starting things because I was too tired
    7 - I was so tired it was hard for me to pay attention
    8 - I was too tired to do sports or exercise
    9 - I was too tired to do things outside
    10 - I was too tired to enjoy the things I like to do
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    Parent Fatigue Questionnaire

    PARENT REPORT for YOUNG CHILDREN (age < 18)

     

    Please mark one response for each question or statement.

    If you do not understand a question, please ask for help.

    In the past 7 days...

    1 - Being tired made it hard for my child to play or go out with friends as much as he/she would like
    2 - My child felt weak
    3 - My child got tired easily
    4 - Being tired made it hard for my child to keep up with schoolwork
    5 - My child had trouble finishing things because he/she was too tired
    6 - My child had trouble starting things because he/she was too tired
    7 - My child was so tired it was hard for him/her to pay attention
    8 - My child was too tired to do sports or exercise
    9 - My child was too tired to do things outside
    10 - My child was too tired to enjoy the things he/she likes to do
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    Pediatric Upper Extremity Questionnaire

    YOUNG CHILDREN REPORT (age < 18)

     

    Please mark one response for each question or statement.

    If you do not understand a question, please ask for help.

    In the past 7 days...

    1 - I could button my shirt or pants
    2 - I could open a jar by myself
    3 - I could open the rings in school binders
    4 - I could pour a drink from a full pitcher
    5 - I could pull a shirt on over my head by myself
    6 - I could pull open heavy doors
    7 - I could put on my shoes by myself
    8 - I could use a key to unlock a door
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    Parent Upper Extremity Questionnaire

    PARENT REPORT for YOUNG CHILDREN (age < 18)

     

    Please mark one response for each question or statement.

    If you do not understand a question, please ask for help.

    In the past 7 days...

    1 - My child could button his/her shirt or pants
    2 - My child could open a jar by himself/herself
    3 - My child could open the rings in school binders
    4 - My child could pour a drink from a full pitcher
    5 - My child could pull a shirt on over his/her head without help
    6 - My child could pull open heavy doors
    7 - My child could put on his/her shoes without help
    8 - My child could use a key to unlock a door
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    Pediatric Sleep Disturbance Questionnaire

    YOUNG CHILDREN REPORT (age < 18)

     

    Please mark one response for each question or statement.

    If you do not understand a question, please ask for help.

    In the past 7 days...

    1 - I had difficulty falling asleep 
    2 - I slept through the night
    3 - I had a problem with my sleep
    4 - I had trouble sleeping
    5 - It took me a long time to fall asleep
    6 - I worried about not being able to fall asleep
    7 - I woke up at night and had trouble falling back to sleep
    8 - I tossed and turned at night
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    Parent Sleep Disturbance Questionnaire

    PARENT REPORT for YOUNG CHILDREN (age < 18)

     

    Please mark one response for each question or statement.

    If you do not understand a question, please ask for help.

    In the past 7 days...

    1 - My child had difficulty falling asleep 
    2 - My child slept through the night
    3 - My child had a problem with his/her sleep
    4 - My child had trouble sleeping
    5 - It took my child a long time to fall asleep
    6 - My child worried about not being able to fall asleep
    7 - My child woke up at night and had trouble falling back to sleep
    8 - My child tossed and turned at night
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    Pediatric Positive Affect Questionnaire

    YOUNG CHILDREN REPORT (age < 18)

     

    Please mark one response for each question or statement.

    If you do not understand a question, please ask for help.

    In the past 7 days...

    1 - I felt happy
    2 - I felt great
    3 - I felt cheerful
    4 - I felt joyful
    5 - I was in a good mood 
    6 - I felt refreshed
    7 - I felt calm
    8 - I felt peaceful
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    Parent Positive Affect Questionnaire

    PARENT REPORT for YOUNG CHILDREN (age < 18)

     

    Please mark one response for each question or statement.

    If you do not understand a question, please ask for help.

    In the past 7 days...

    1 - My child felt happy
    2 - My child felt great
    3 - My child felt cheerful
    4 - My child felt joyful
    5 - My child was in a good mood
    6 - My child felt refreshed
    7 - My child felt calm
    8 - My child felt peaceful
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    Pediatric Strength Impact Questionnaire

    YOUNG CHILDREN REPORT (age < 18)

     

    Please mark one response for each question or statement.

    If you do not understand a question, please ask for help.

    In the past 7 days...

    1 - How many days were you strong enough to carry heavy things with your hands?
    2 - How many days were you strong enough to go up and down stairs?
    3 - How many days were you strong enough to open a heavy door?
    4 - How many days were you strong enough to jump up and down?
    5 - How many days were you strong enough to pour a drink from a full pitcher or carton?
    6 - How many days were you strong enough to open a jar by yourself?
    7 - How many days were you strong enough to lift heavy things over your head?
    8 - How many days were you strong enough to reach above your head to get heavy things?
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    Parent Strength Impact Questionnaire

    PARENT REPORT for YOUNG CHILDREN (age < 18)

     

    Please mark one response for each question or statement.

    If you do not understand a question, please ask for help.

    In the past 7 days...

    1 - How many days was your child strong enough to carry heavy things with his/her hands?
    2 - How many days was your child strong enough to go up and down stairs?
    3 - How many days was your child strong enough to open a heavy door?
    4 - How many days was your child strong enough to jump up and down?
    5 - How many days was your child strong enough to pour a drink from a full pitcher or carton?
    6 - How many days was your child strong enough to open a jar by himself/herself?
    7 - How many days was your child strong enough to lift heavy things over his/her head?
    8 - How many days was your child strong enough to reach above his/her head to get heavy things?
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    If you have finished filling out the questionnaire, please send your answer by pressing the Submit button.

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