ARDS Cognitive Questionnaire

On Tuesday, May 4, 1999, Sue Peterson spoke with Dr. William H. Shull, Jr., who is an Assistant Professor of Rehabilitative Medicine and Director of Trauma Rehabilitation specializing in brain injury. Dr. Shull is with the University of Pennsylvania School of Medicine. The ARDS Support Center  has heard from many ARDS survivors and their families about some of the cognitive changes noted after surviving ARDS, such as short term memory loss, difficulty in concentration, depression, anxiety and trouble with executive functions. We have received many questions from you regarding this. We have learned that many of your doctors do not address these issues and do not offer a great deal of assistance in this area. This is probably because no research has been done, to our knowledge, in the area of pulmonary injury causing chemical changes/injury to the brain. This is your opportunity as ARDS survivors and as families of loved ones who have survived ARDS to start the ball rolling in getting more attention and research into this very important area. We have written an informal survey and would greatly appreciate your responses. They are important as we move forward and attempt to understand more about ARDS. We ask you to answer these questions as fully as you can and also at the bottom of the survey to write about any other problems/questions that you have experienced in your recovery process. Your responses will be forwarded to Dr. Shull. Dr. Shull believes "this will definitely lead to research and more importantly, to improved awareness of the importance of rehab doctors in helping the pulmonary physician treat the ARDS survivor, and most importantly, to improved quality of life for patients and families".

If you are willing to participate in Future Research Projects, on a confidential basis, please fill out the
questionnaire that is available by clicking this address Future Research. When complete just click the submit button. Your name and the information you provide will be retained for possible future use.

Note: If you have problems using this form, please click here -->  Old survey

Please answer all the questions
Then submit the form.

Section A

Tell us how to get in touch with you:

Name
E-mail
Confirm E-mail
Telephone

Section B

1.) Do you have problems with loss of memory? If so, please describe the problems.

Yes
No



2.) Do you have trouble concentrating?

Yes
No

3.) Do you have trouble organizing your day?

Yes
No

4.) Is it difficult to pay close attention to TV?

Yes
No

5.) Are you able to comprehend what you read?

Yes
No

6.) Do you find yourself having to go back and re-read paragraphs that you just read?

Yes
No

7.) Do you lose your place while reading?

Yes
No

8.) Do you have problems with basic self-care?

Yes
No

9.) Do you have trouble driving?

Yes
No

10.) Do you have problems with community based mobility skills, i.e. walking, attending meetings and understanding what was said, etc.?

Yes
No

11.) Do you have difficulty with fine motor skills?

Yes
No

12.) Do you feel that your judgment is impaired?

Yes
No

13.) Do you feel that you have poor safety awareness?

Yes
No

14.) Do you find yourself suddenly being impulsive?

Yes
No

15.) Are you having problems with sleep/wake cycles? If so, please describe.

Yes
No


16.) Have you noticed any changes in your personality?

Yes
No

17.) Please tell us about any other areas in your mental thinking/anxiety/emotions that you are having problems with.





Thank you for taking the time to complete the survey !

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Copyright © 2000 ASC.  All rights reserved.
Revised: June 26, 2000
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