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. Author manuscript; available in PMC: 2014 May 15.
Published in final edited form as: Head Neck. 2012 Mar 20;35(3):354–360. doi: 10.1002/hed.22980

Table 1.

Survey Questions

Presence of Body-Related Concerns
  • 1)

    Please indicate if at any time following head and neck cancer diagnosis and/or treatment you experienced concerns or embarrassment about any of the following:

  • 2)

    Please indicate if you are currently concerned or embarrassed about (circle all that apply):

    • Scarring/disfigurement

    • Skin discoloration

    • Swelling

    • Weight loss

    • Weight gain

    • Hair loss

    • Eating around others*

    • Using a prosthetic device

    • Speaking*

    • Loss of teeth

    • Drooling

    • Presence of stoma/trach

    • Removal of eye

    • removal of ear

    • Removal of nose

    • Other appearance concern

Cognitive/Behavioral Difficulties Associated with Body-Related Concerns
  • 3)

    Since your diagnosis, have you experienced any of the following:

    1. Frequent thoughts about appearance changes

    2. Avoidance of social activities because of appearance changes

    3. Avoidance of social activities because of changes to your speech

    4. Avoidance of activities because of changes to your eating habits

    5. Increased amount of time engaged in grooming activities

    6. Avoidance of grooming activities

    7. Seeking reassurance from others about your appearance

Interest in Psychosocial Care/Intervention
  • 4)

    Would you like to receive additional resources to help you cope with appearance-related changes (including discomfort with scarring, weight changes, hair loss, managing embarrassment about eating, speaking, feeling more comfortable in social situations)?

  • 5)

    What type of resources would you be interested in (whether now or previously?)

  • 6)

    Based on your experience, what is the best time to incorporate treatment to help patients cope with appearance-related changes (before treatment, during active treatment, at completion of active treatment)

Note.

*

Participants endorsing either of these two items were placed in speech/eating concerns group (SE group). Those endorsing any other concern item were placed in the group that denied speech and eating issues, but reported other types of concerns largely tied to appearance (AC group).