Table 2 List of questions for the patients and caregivers
From: The updated retrospective questionnaire study of sporadic inclusion body myositis in Japan
Basic information | Hospital |
Date | |
Doctor’s name | |
Patient’s Name | |
Date of birth and age | |
Sex | |
Address/Phone/E-mail | |
Life/Past History | Development |
Exercise Capacity at School | |
Works | |
Preference of food | |
Economic matters | |
Symptoms | Initial symptom: unable to stand-up etc. |
Milestones: wheelchair, cane, dysphagia | |
Mental/psychological stress | |
Diagnosis | Age at admission |
Method of diagnosis: muscle biopsy | |
Family history, Past history | |
Therapy | Rehabilitation |
Steroid/IVIG/others | |
Interferon | |
For Caregiver | Activities of daily life |
Mental/psychological stress | |
Cognitive decline: none, age-appropriate, diagnosed as dementia, medication | |
Functional Scale | Modified IBMFRS |