Chronic pain in the chest wall, breast and armpit after breast cancer surgery is a common clinical problem, we have conducted this survey for post-operative patients. We hope this will be of benefit to you. Wang Xiaohui, Department of General Surgery, Xuanwu Hospital, Capital Medical University
Questionnaire
Age, date of surgery, month, year
In order to better treat you, please take a few minutes to complete this questionnaire
1. What kind of surgery did you undergo?
□ Breast-conserving surgery □ Total mastectomy
2. What kind of surgery did you have for your armpit?
□ axillary lymph node biopsy □ axillary lymph node dissection
3. when did you receive chemotherapy?
□ preoperative □ postoperative □ both preoperative and postoperative
4. Have you received radiotherapy?
□ Yes □ No
5. Did you have any pain in the breast area, lateral chest wall, armpit or upper extremity before surgery? (Breast area is defined as the breast undergoing surgery or the chest wall after total mastectomy)
□ Yes □ No
Do you have any pain in the breast area, lateral chest wall, axilla or upper extremity on the operated side after surgery?
□ Yes □ No
If no, please answer question 19 directly
7. If yes, please select the location where you feel the pain (you can choose more than one)
□ breast area □ lateral chest wall □ armpit □ upper limb
Use the numerical scale 0-10 to represent different degrees of pain, 0 being no pain, 10 being severe pain. 1-3: mild pain; 4-6: moderate pain; 7-10: severe pain. Please circle a number for yourself that best represents your pain level. 8.
8. If your pain is in the breast area, please circle the number that best represents your pain level.
□ 0 □ 1 □ 2 □ 3 □ 4 □ 5 □ 6 □ 7 □ 8 □ 9 □ 10
9. If your pain is in the breast area, how often does it occur?
□ Daily or almost daily □ 1-3 days per week □ Occasionally
10. If your pain is in the lateral chest wall, please circle a number for yourself that best represents your pain level.
□ 0 □ 1 □ 2 □ 3 □ 4 □ 5 □ 6 □ 7 □ 8 □ 9 □ 10
11. If your pain is in the lateral chest wall, how often does it occur?
□ daily or almost daily □ 1-3 days per week □ occasionally
12. If your pain is in your armpit, please circle the number that best represents your pain level
□ 0 □ 1 □ 2 □ 3 □ 4 □ 5 □ 6 □ 7 □ 8 □ 9 □ 10
If your pain is in your armpit, how often does it occur?
□ daily or almost daily □ 1-3 days per week □ occasionally
14. If your pain is in your upper extremity, please circle the number that best represents your pain level
□ 0 □ 1 □ 2 □ 3 □ 4 □ 5 □ 6 □ 7 □ 8 □ 9 □ 10
15. If your pain is in the upper extremity, how often does it occur?
□ Daily or almost daily □ 1-3 days per week □ Occasionally
16. In the past 3 months, have you visited a hospital for the above-mentioned pain?
□ Yes □ No
17. have you ever taken pain medication for the above pain?
□ Yes □ No
18. have you ever received other treatments for the above pain, such as physical therapy, massage, acupuncture, etc.?
□ Yes □ No
Do you have any sensory disturbance, discomfort, etc. in the breast area, lateral chest wall, armpit or upper extremity on the side of the surgery?
□ Yes □ No
If no, please answer question 21 directly
20. If yes, please select the location of your sensory disturbance or discomfort (multiple choices are allowed)
□ Breast area □ Lateral chest wall □ Armpit □ Upper extremity
21. Do you often have pain in other parts of your body, such as lower back pain, headache, etc.?
□ Yes □ No