Annelotte van Bommel

139 Information provision of immediate breast reconstruction SUPPLEMENTARY APPENDIX 2: QUESTIONNAIRE The following questions are covering understated aspects: Questions on health and treatment: - general health: Q1, Q2. - breast cancer treatment: Q3 – Q5 - breast reconstruction: Q17 – 21 Shared decision-making aspects: - bothpatientandphysicianacknowledgeadecision isrequired(byknowingthat IBR isanoption):Q7–9, Q16 - understandingandweighingallavailable informationaboutthetreatmentoptions:Q10,Q12,Q13;Q6, Q15 - incorporating the patient’s preferences in the final decision: Q11, Q22 – 24 Questions on patient’s background: - dateofbirth,nationality,educational level,workingstatus,relationshipstatus,breastsize,body length and weight, andmenopausal status: Q46 – 57 1. Howwas, in your own perception, your physical health over the past threemonths? Excellent – very well – well –moderate – bad 2. Howwas, in your own perception, your mental health over the past threemonths? Excellent – very well – well –moderate – bad 3. What kind of surgery did you receive? Amputation – amputation including axillary lymph node dissection – other 4. When did you receive this surgical procedure? [fill in date DD/MM/YYYY] 5. Did you receive surgery on one or both breasts? Both breasts (double-sided) because of cancer in both breasts – both breasts (double-sided) because of cancer in a single breast while other side preventive – single breast (single-sided) 6. Did you have a consultation with a radiotherapist prior to your surgery? Yes – no – can’t remember – not applicable since I did not receive radiotherapy 7. Where you informed on possible treatment with an immediate breast reconstruction prior to receiving your surgical treatment? Yes – no – can’t remember 8. Where you informed on possible treatment with a delayed breast reconstruction prior to receiving your surgical treatment? Yes – no – can’t remember 9. Whereyou informedonthepossibilityofbreastprosthesispriortoreceivingyoursurgicaltreatment (when not opting for breast reconstruction)? Yes – no – can’t remember 7