Quality of Recovery - KP Dept. of Anesthesia (QoR-15)

Help us at Kaiser Permanente improve our care by sharing your experience with pain management following your surgery. Please wait until 2 days after your surgery to fill this out and answer all of the questions. Please do not add any identifying personal information. This survey is completely anonymous. Thank you so much for your time. Best wishes for a speedy recovery.

	None of the time 0	1	2	3	4	Sometimes 5	6	7	8	9	All of the time 10
Able to breath easily	Able to breath easily None of the time 0	Able to breath easily 1	Able to breath easily 2	Able to breath easily 3	Able to breath easily 4	Able to breath easily Sometimes 5	Able to breath easily 6	Able to breath easily 7	Able to breath easily 8	Able to breath easily 9	Able to breath easily All of the time 10
Able to enjoy food	Able to enjoy food None of the time 0	Able to enjoy food 1	Able to enjoy food 2	Able to enjoy food 3	Able to enjoy food 4	Able to enjoy food Sometimes 5	Able to enjoy food 6	Able to enjoy food 7	Able to enjoy food 8	Able to enjoy food 9	Able to enjoy food All of the time 10
Feeling rested	Feeling rested None of the time 0	Feeling rested 1	Feeling rested 2	Feeling rested 3	Feeling rested 4	Feeling rested Sometimes 5	Feeling rested 6	Feeling rested 7	Feeling rested 8	Feeling rested 9	Feeling rested All of the time 10
Have you had a good sleep	Have you had a good sleep None of the time 0	Have you had a good sleep 1	Have you had a good sleep 2	Have you had a good sleep 3	Have you had a good sleep 4	Have you had a good sleep Sometimes 5	Have you had a good sleep 6	Have you had a good sleep 7	Have you had a good sleep 8	Have you had a good sleep 9	Have you had a good sleep All of the time 10
Able to look after personal hygiene and use the toilet unaided	Able to look after personal hygiene and use the toilet unaided None of the time 0	Able to look after personal hygiene and use the toilet unaided 1	Able to look after personal hygiene and use the toilet unaided 2	Able to look after personal hygiene and use the toilet unaided 3	Able to look after personal hygiene and use the toilet unaided 4	Able to look after personal hygiene and use the toilet unaided Sometimes 5	Able to look after personal hygiene and use the toilet unaided 6	Able to look after personal hygiene and use the toilet unaided 7	Able to look after personal hygiene and use the toilet unaided 8	Able to look after personal hygiene and use the toilet unaided 9	Able to look after personal hygiene and use the toilet unaided All of the time 10
Able to communicate with family or friends	Able to communicate with family or friends None of the time 0	Able to communicate with family or friends 1	Able to communicate with family or friends 2	Able to communicate with family or friends 3	Able to communicate with family or friends 4	Able to communicate with family or friends Sometimes 5	Able to communicate with family or friends 6	Able to communicate with family or friends 7	Able to communicate with family or friends 8	Able to communicate with family or friends 9	Able to communicate with family or friends All of the time 10
Getting support from hospital doctors and nurses or home health staff	Getting support from hospital doctors and nurses or home health staff None of the time 0	Getting support from hospital doctors and nurses or home health staff 1	Getting support from hospital doctors and nurses or home health staff 2	Getting support from hospital doctors and nurses or home health staff 3	Getting support from hospital doctors and nurses or home health staff 4	Getting support from hospital doctors and nurses or home health staff Sometimes 5	Getting support from hospital doctors and nurses or home health staff 6	Getting support from hospital doctors and nurses or home health staff 7	Getting support from hospital doctors and nurses or home health staff 8	Getting support from hospital doctors and nurses or home health staff 9	Getting support from hospital doctors and nurses or home health staff All of the time 10
Do you feel able to return to work or do usual home activities	Do you feel able to return to work or do usual home activities None of the time 0	Do you feel able to return to work or do usual home activities 1	Do you feel able to return to work or do usual home activities 2	Do you feel able to return to work or do usual home activities 3	Do you feel able to return to work or do usual home activities 4	Do you feel able to return to work or do usual home activities Sometimes 5	Do you feel able to return to work or do usual home activities 6	Do you feel able to return to work or do usual home activities 7	Do you feel able to return to work or do usual home activities 8	Do you feel able to return to work or do usual home activities 9	Do you feel able to return to work or do usual home activities All of the time 10
Feeling comfortable and in control	Feeling comfortable and in control None of the time 0	Feeling comfortable and in control 1	Feeling comfortable and in control 2	Feeling comfortable and in control 3	Feeling comfortable and in control 4	Feeling comfortable and in control Sometimes 5	Feeling comfortable and in control 6	Feeling comfortable and in control 7	Feeling comfortable and in control 8	Feeling comfortable and in control 9	Feeling comfortable and in control All of the time 10
Having a feeling of general well-being	Having a feeling of general well-being None of the time 0	Having a feeling of general well-being 1	Having a feeling of general well-being 2	Having a feeling of general well-being 3	Having a feeling of general well-being 4	Having a feeling of general well-being Sometimes 5	Having a feeling of general well-being 6	Having a feeling of general well-being 7	Having a feeling of general well-being 8	Having a feeling of general well-being 9	Having a feeling of general well-being All of the time 10

None of the time
0

Sometimes
5

All of the time
10

Able to breath easily

Able to breath easily None of the time
0

Able to breath easily 1

Able to breath easily 2

Able to breath easily 3

Able to breath easily 4

Able to breath easily Sometimes
5

Able to breath easily 6

Able to breath easily 7

Able to breath easily 8

Able to breath easily 9

Able to breath easily All of the time
10

Able to enjoy food

Able to enjoy food None of the time
0

Able to enjoy food 1

Able to enjoy food 2

Able to enjoy food 3

Able to enjoy food 4

Able to enjoy food Sometimes
5

Able to enjoy food 6

Able to enjoy food 7

Able to enjoy food 8

Able to enjoy food 9

Able to enjoy food All of the time
10

Feeling rested

Feeling rested None of the time
0

Feeling rested 1

Feeling rested 2

Feeling rested 3

Feeling rested 4

Feeling rested Sometimes
5

Feeling rested 6

Feeling rested 7

Feeling rested 8

Feeling rested 9

Feeling rested All of the time
10

Have you had a good sleep

Have you had a good sleep None of the time
0

Have you had a good sleep 1

Have you had a good sleep 2

Have you had a good sleep 3

Have you had a good sleep 4

Have you had a good sleep Sometimes
5

Have you had a good sleep 6

Have you had a good sleep 7

Have you had a good sleep 8

Have you had a good sleep 9

Have you had a good sleep All of the time
10

Able to look after personal hygiene and use the toilet unaided

Able to look after personal hygiene and use the toilet unaided None of the time
0

Able to look after personal hygiene and use the toilet unaided 1

Able to look after personal hygiene and use the toilet unaided 2

Able to look after personal hygiene and use the toilet unaided 3

Able to look after personal hygiene and use the toilet unaided 4

Able to look after personal hygiene and use the toilet unaided Sometimes
5

Able to look after personal hygiene and use the toilet unaided 6

Able to look after personal hygiene and use the toilet unaided 7

Able to look after personal hygiene and use the toilet unaided 8

Able to look after personal hygiene and use the toilet unaided 9

Able to look after personal hygiene and use the toilet unaided All of the time
10

Able to communicate with family or friends

Able to communicate with family or friends None of the time
0

Able to communicate with family or friends 1

Able to communicate with family or friends 2

Able to communicate with family or friends 3

Able to communicate with family or friends 4

Able to communicate with family or friends Sometimes
5

Able to communicate with family or friends 6

Able to communicate with family or friends 7

Able to communicate with family or friends 8

Able to communicate with family or friends 9

Able to communicate with family or friends All of the time
10

Getting support from hospital doctors and nurses or home health staff

Getting support from hospital doctors and nurses or home health staff None of the time
0

Getting support from hospital doctors and nurses or home health staff 1

Getting support from hospital doctors and nurses or home health staff 2

Getting support from hospital doctors and nurses or home health staff 3

Getting support from hospital doctors and nurses or home health staff 4

Getting support from hospital doctors and nurses or home health staff Sometimes
5

Getting support from hospital doctors and nurses or home health staff 6

Getting support from hospital doctors and nurses or home health staff 7

Getting support from hospital doctors and nurses or home health staff 8

Getting support from hospital doctors and nurses or home health staff 9

Getting support from hospital doctors and nurses or home health staff All of the time
10

Do you feel able to return to work or do usual home activities

Do you feel able to return to work or do usual home activities None of the time
0

Do you feel able to return to work or do usual home activities 1

Do you feel able to return to work or do usual home activities 2

Do you feel able to return to work or do usual home activities 3

Do you feel able to return to work or do usual home activities 4

Do you feel able to return to work or do usual home activities Sometimes
5

Do you feel able to return to work or do usual home activities 6

Do you feel able to return to work or do usual home activities 7

Do you feel able to return to work or do usual home activities 8

Do you feel able to return to work or do usual home activities 9

Do you feel able to return to work or do usual home activities All of the time
10

Feeling comfortable and in control

Feeling comfortable and in control None of the time
0

Feeling comfortable and in control 1

Feeling comfortable and in control 2

Feeling comfortable and in control 3

Feeling comfortable and in control 4

Feeling comfortable and in control Sometimes
5

Feeling comfortable and in control 6

Feeling comfortable and in control 7

Feeling comfortable and in control 8

Feeling comfortable and in control 9

Feeling comfortable and in control All of the time
10

Having a feeling of general well-being

Having a feeling of general well-being None of the time
0

Having a feeling of general well-being 1

Having a feeling of general well-being 2

Having a feeling of general well-being 3

Having a feeling of general well-being 4

Having a feeling of general well-being Sometimes
5

Having a feeling of general well-being 6

Having a feeling of general well-being 7

Having a feeling of general well-being 8

Having a feeling of general well-being 9

Having a feeling of general well-being All of the time
10

	None of the time 0	1	2	3	4	Sometimes 5	6	7	8	9	All of the time 10
Moderate pain	Moderate pain None of the time 0	Moderate pain 1	Moderate pain 2	Moderate pain 3	Moderate pain 4	Moderate pain Sometimes 5	Moderate pain 6	Moderate pain 7	Moderate pain 8	Moderate pain 9	Moderate pain All of the time 10
Severe pain	Severe pain None of the time 0	Severe pain 1	Severe pain 2	Severe pain 3	Severe pain 4	Severe pain Sometimes 5	Severe pain 6	Severe pain 7	Severe pain 8	Severe pain 9	Severe pain All of the time 10
Nausea or vomiting	Nausea or vomiting None of the time 0	Nausea or vomiting 1	Nausea or vomiting 2	Nausea or vomiting 3	Nausea or vomiting 4	Nausea or vomiting Sometimes 5	Nausea or vomiting 6	Nausea or vomiting 7	Nausea or vomiting 8	Nausea or vomiting 9	Nausea or vomiting All of the time 10
Feeling worried or anxious	Feeling worried or anxious None of the time 0	Feeling worried or anxious 1	Feeling worried or anxious 2	Feeling worried or anxious 3	Feeling worried or anxious 4	Feeling worried or anxious Sometimes 5	Feeling worried or anxious 6	Feeling worried or anxious 7	Feeling worried or anxious 8	Feeling worried or anxious 9	Feeling worried or anxious All of the time 10
Feeling sad or depressed	Feeling sad or depressed None of the time 0	Feeling sad or depressed 1	Feeling sad or depressed 2	Feeling sad or depressed 3	Feeling sad or depressed 4	Feeling sad or depressed Sometimes 5	Feeling sad or depressed 6	Feeling sad or depressed 7	Feeling sad or depressed 8	Feeling sad or depressed 9	Feeling sad or depressed All of the time 10

None of the time
0

Sometimes
5

All of the time
10

Moderate pain

Moderate pain None of the time
0

Moderate pain 1

Moderate pain 2

Moderate pain 3

Moderate pain 4

Moderate pain Sometimes
5

Moderate pain 6

Moderate pain 7

Moderate pain 8

Moderate pain 9

Moderate pain All of the time
10

Severe pain

Severe pain None of the time
0

Severe pain 1

Severe pain 2

Severe pain 3

Severe pain 4

Severe pain Sometimes
5

Severe pain 6

Severe pain 7

Severe pain 8

Severe pain 9

Severe pain All of the time
10

Nausea or vomiting

Nausea or vomiting None of the time
0

Nausea or vomiting 1

Nausea or vomiting 2

Nausea or vomiting 3

Nausea or vomiting 4

Nausea or vomiting Sometimes
5

Nausea or vomiting 6

Nausea or vomiting 7

Nausea or vomiting 8

Nausea or vomiting 9

Nausea or vomiting All of the time
10

Feeling worried or anxious

Feeling worried or anxious None of the time
0

Feeling worried or anxious 1

Feeling worried or anxious 2

Feeling worried or anxious 3

Feeling worried or anxious 4

Feeling worried or anxious Sometimes
5

Feeling worried or anxious 6

Feeling worried or anxious 7

Feeling worried or anxious 8

Feeling worried or anxious 9

Feeling worried or anxious All of the time
10

Feeling sad or depressed

Feeling sad or depressed None of the time
0

Feeling sad or depressed 1

Feeling sad or depressed 2

Feeling sad or depressed 3

Feeling sad or depressed 4

Feeling sad or depressed Sometimes
5

Feeling sad or depressed 6

Feeling sad or depressed 7

Feeling sad or depressed 8

Feeling sad or depressed 9

Feeling sad or depressed All of the time
10

Quality of Recovery - KP Dept. of Anesthesia (QoR-15) - Roseville CRNA

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* 1. Where did you have your surgery?

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* 2. What type of surgery did you have done?

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* 3. How many days ago was your surgery?

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* 4. How have you been feeling in the last 24 hours?

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* 5. Have you had any of the following in the last 24 hours?

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* 6. When were you discharged to home or living facility following surgery?

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* 7. Overall, how satisfied or dissatisfied were you with your last anesthetic?

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* 8. Optional- The nurse anesthetist for my procedure was:

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* 9. Do you have any other comments, questions, or concerns regarding anesthesia?