Gordon D. Rubenfeld, MD MSc
Associate Professor
Division of Pulmonary and Critical Care Medicine
Box 359762
Harborview Medical Center
325 9th Ave
Seattle WA 98104-2499
FAX: 206.731.8584
 
 
   
 
 
Survivor and family survey
to identify problems and solutions after ARDS		  
   
Q1 I am a survivor of ARDS (if NO, skip to Q6)  
YES  
NO  
   
Q2 Current AGE Years ______  
   
Q3 Year in hospital with ARDS 19 ___  
   
Q4 Reason you had ARDS (check one)  
   
Pneumonia  
Trauma (motor vehicle crash, etc)  
Inflammation of pancreas  
Pregnancy  

After major surgery  
Chemotherapy  
Other ________________  
Don't know  
   
Q5 Who helped you get better after your ARDS? (check all that apply)  
   
Husband/Wife  
Brother/Sister  
Children  
Other family members  
Co-workers  
Friends  
Myself  
Other ________________  
     

Q6

We are very interested in the problems you encountered as you (or your loved one) recovered from ARDS. This includes medical problems like skin ulcers and pain, psychological and social problems like depression and getting back to your regular life, and other physical problems like weakness, numbness, and mobility.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

If you need more space, just continue on another sheet of paper - label your answer.

  
     

Q7

We would like to know about treatments, resources, or clinicians that you (or your loved one) found to really improve your recovery after ARDS. Tell us as much detail as you can about the things that helped you get better once you left the hospital.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

If you need more space, just continue on another sheet of paper - label your answer.

  
   
Q8 We would also like to know about treatments, resources, or clinicians that you (or your loved one) tried but found that they really didn't help you much at all. Tell us as much detail as you can about the things you tried that didn't work.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

If you need more space, just continue on another sheet of paper - label your answer.

  
   
Q9 Finally, sometimes people run into problems getting the services they need. Tell us about the problems you had with insurance companies, hospitals, transportation, and doctors or other clinicians in trying to get treatments after ARDS.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

If you need more space, just continue on another sheet of paper - label your answer.

  
     
  Thank you for your time in filling out this survey.