ICC-COMPRESSION QUESTIONNAIRE
Dear patient,

FOR PATIENTS (ICC-CQ-P)

You will receive/ have received a new compression product.
By filling out this questionnaire we would like to know your personal feeling and experience
concerning your compression therapy.
The questionnaire has to be filled out before using the tested compression (part 1) and at
certain time intervals after the start (part 2).

Next to some of the questions there is an 11-point scale. You should circle the number thatmatches your situation the best. Only if the question is not applicable for your situation, youhave to tick ‘not applicable’.
For example: Are you able to put on shoes over your compression device? You only
may tick ‘not applicable’ if the compression device does not cover your foot (but only
covers the arm in case of an arm sleeve for example).
It is necessary to answer each question.
Thank you for your cooperation!

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Part 1. Assessment by patient - before start of tested compression
Date: …
ID patient:

Hour of the day: …

Physical functioning
If you need to apply compression at the level of your hand, arm or trunk, you have to scorethe questions under ‘upper part of the body’.
Otherwise you have to score the questions under ‘lower part of the body’.
IN CASE YOU WEAR THE TESTED COMPRESSION AT THE UPPER PART OF THE BODY
How do you rate (without compression) …
1. your ability to moveyour wrist/ fingers?
2. your ability to moveyour elbow?
3. your ability to moveyour shoulder?
4. your ability to use aspoon?

Not able at all

Completely able

Not able at all

Completely able

Not able at all

Completely able

Not able at all

Completely able

IN CASE YOU WEAR COMPRESSION AT THE LOWER PART OF THE BODY
How do you rate (without compression) …
1. your ability to moveyour ankle?

Not able at all

2. your ability to moveyour knee?

Not able at all

4. your ability to walk?

Not able at all

3. your ability to moveyour hip?

Not able at all

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Completely able
Completely able
Completely able
Completely able

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FOR ALL PATIENTSHow well are you (physically or mentally) able to:
5. carry out
your job(paid work)?

Not able at all

6. completehouseholdchores?

Not able at all

My score relates to the following job: …………………………………

7. practicesports?

Not able at all

Not able at all

My score relates to the following leisure activities: ……………………………………….

9. carry out social
activities withfriends (e.g. go
to a party, go out
for dinner)?

(Not applicable, I
have no job*)

Completely able
(Not applicable, I do notcomplete household chores*)

My score relates to the following sports: ……………………………………………………….

8. carry out
leisureactivities?

Completely able

Not able at all

Completely able
(Not applicable, I do notpractise sports*)

Completely able

(Not applicable, I do notcarry out leisure activities*)

Completely able
(Not applicable, I do not carryout social activities*)* And I do not perform this activity because of the disease that is treated with the compression, but
because of another reason.

In case you do not perform the activity because of your disease, you have to score 0 – not able at all.

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Disease-related symptoms

Here we rate your symptoms associated with your disease (for example lymphoedema,lipoedema, or venous insufficiency).
Do you experience in relation to your disease, that will be treated with the tested
compression, …
Not at all

A lot
Absol

1. pain?

2. a loss of muscle
strength?
3. heaviness?
4. swelling?

5. tight skin?
6. tingling?

7. leakage of fluid (outof skin)?
Not at all

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A lot
Absol

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Part 2. Assessment of tested compression by patient – after
application of tested compression (during follow-up)
Date: …
ID patient:

Hour of the day: …

General questions

1. Which compression device/ system do you use? If possible, give the manufacturer andtype of compression garment, bandage or pneumatic compression. For compression
garments: you can copy the text of the product label: …
2. What is your professional status: retired/ not working/ working
If working,indicate kind of work: …
sitting …… % of the timestanding ……. % of the time
walking ……. % of the time
3. Do you practise sports: yes/ no
Indicate your 3 most important sport activities: …

4. Do you have leisure activities (outside of sports): yes/ no
Indicate your 3 most important leisure activities: …
5. What is your family situation: married/ living together/ single

Dosage of compression

1. During the past week, how many days have you worn/ used the tested compression
device/ system? …
days
2. How many hours during daytime (during waking hours) did you wear/ use thecompression on average during the past week? … hours during daytime

3. How many hours at night (lying in bed) did you wear/ use the compression on averageduring the past week? … hours at night

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5!

Application and removing of compression

Firstly, you have to judge the ease of applying/ removing your compression
product/ system when you have to apply/ remove it independently, without help
from others or material.
Thereafter, only if you normally have help from others or from donning system,
you have to judge the ease of application/ removing of your compression product/system with this help.
APPLICATION OF COMPRESSION

1. Are you able to put on the compression device/ system yourself, without help fromothers or donning system?
Completely able

Not able at all

2. Do you use help from others or donning system to put on your compression? Yes/ noIf no, go to question 3.

If yes, answer a. and b.

a. Indicate the kind of help you use to put on the compression:
O I receive help from other persons
O I use gloves as donning system
O I use a silk foot slip as donning system
O I use bag with double layer as donning system
O I use a butler as donning system (see picture)
O I use something else, please indicate: …

b. Are you able to put on the compression device with help from others or donningsystem?
Not able at all

Completely able

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REMOVING OF COMPRESSION
3. Are you able to take off the compression device yourself, without help from others ordoffing system?
Completely able

Not able at all

4. Do you use help from others or doffing system to take off your compression? Yes/ noIf no, go to domain ‘compression comfort’.
If yes, answer a. and b:

a. Indicate the kind of help you use to take off thecompression:
O I receive help from other persons
O I use a butler off (see picture)
O I use a bag with one layer
O I use something else, please indicate: …

b. Are you able to take off the compression device with help from others or donningsystem?
Completely able

Not able at all

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1. Are you able to put on your usual shoes you like to wear over the compression device/system?
Completely able

Not able at all(Not applicable, I
do not wear shoes
over mycompression)

2. Are you able to wear clothes you like to wear over the compression device/ system?
Not able at all

Completely able

3. How does the compression device/ system feel immediately after you have put it on (thefirst day after washing)? I find the compression device/ system …
Not comfortable at allAbsolutely comfortable

4. How does the compression device/ system feel later on, during the day? I find thecompression device/ system …
Not comfortable at all

Absolutely comfortable(Not applicable, I do notwear compression
during daytime)

5. How does the compression device/ system feel later on, during the night? I find thecompression device/ system …
Not comfortable at all

Absolutely comfortable(Not applicable, I do notwear compression duringthe night)

6. How do you feel about the appearance of the compression device/ system? I find theappearance …
Not acceptable at all

Absolute acceptable

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Complications of compression

Does the compression device/ system cause …
Not at allA lot

1. General skin irritation(redness)?

2. Tender/ sore spots(because of too highlocal pressure of friction)?
3. Damage of skin?
4. Itching?

5. Warmth (if outside
temperature is <25°C)?
6. Throbbing?
7. Cramps?

8. Cutting in?

9. Sliding down(slippage)?

10. Local swelling?
11. Bulky feeling?

12. Too tight feeling?

13. Other specific problems:……………………………
(please indicate theproblem)……………………………
(please indicate theproblem)

Not at all

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A lot9Physical functioning in relation to compression
If you need to wear/ use compression at the level of your hand, arm or trunk, you have toscore the questions under ‘upper part of the body’.
Otherwise you have to score the questions under ‘lower part of the body’.
IN CASE YOU WEAR THE TESTED COMPRESSION AT THE UPPER PART OF THE BODY

How do you rate, while you are wearing/ using the tested compression, …
1. your ability to moveyour wrist/ fingers?
2. your ability to moveyour elbow?
3. your ability to moveyour shoulder?
4. your ability to use aspoon?

Not able at all

Not able at all

Not able at all

Not able at all

Completely able
Completely able

Completely able

Completely able

IN CASE YOU WEAR THE TESTED COMPRESSION AT THE LOWER PART OF THE BODY

How do you rate, while you are wearing/ using the tested compression, …
1. your ability to moveyour ankle?
2. your ability to moveyour knee?
3. your ability to moveyour hip?
4. your ability to walk?

Not able at all

Completely able

Not able at all

Completely able

Not able at all

Not able at all

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Completely able

Completely able

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FOR ALL PATIENTSHow well are you (physically or mentally) able to:
5. carry out
your job(paid work)?

Not able at all

6. completehouseholdchores?

Not able at all

My score relates to the following job: …………………………………

7. practicesports?

Not able at all

Not able at all

My score relates to the following leisure activities: ……………………………………….

9. carry out social
activities withfriends (e.g. goto a party, go outfor dinner)?

(Not applicable, I
have no job*)
Completely able
(Not applicable, I do notcomplete household chores*)

My score relates to the following sports: ……………………………………………………….

8. carry outleisureactivities?

Completely able

Not able at all

Completely able
(Not applicable, I do notpractise sports*)

Completely able

(Not applicable, I do notcarry out leisure activities*)

Completely able

(Not applicable, I do notcarry out social
activities*)* And I do not perform this activity because of the disease that is treated with the compression, but
because of another reason.

In case you do not perform the activity because of your disease, you have to score 0 – not able at all.

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11Disease-related symptoms

Here we rate your symptoms associated with your disease (for example lymphoedema,lipoedema, or venous insufficiency).

Do you experience in relation to your disease, that is treated with the tested compression, …
Not at all

A lot
Absol

1. pain?

2. a loss of muscle
strength?
3. heaviness?
4. swelling?

5. tight skin?
6. tingling?

7. leakage of fluid (outof skin)?
Not at all

A lot
Absol

General experience

8. Compared to your previous experiences with other compression devices, I judge thenew device as …
Completely superior

Completely inferior

Please indicate the product name and time of your previous experience(and in case of compression garment, also the compression class):(Not applicable, I haveno previous experience)…………………………………………………………………………………………………….
………………………………………………………………………………………………………………

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