Quality of Life Questionnaire

Below is a list of statements that other people with your illness have said are important. By checking one (1) number per line, please indicate how true each statement has been for you during the past 7 days.
Patient Name
Email

 

PHYSICAL WELL BEING

Not at all

A little bit

Some what

Quite a bit

Very Much

             

GP1

I have a lack of energy

0

1 2 3 4
             

GP2

I have nausea

0

1 2 3 4
             

GP3

Because of my physical condition, I have trouble meeting the needs of my family

0

1 2 3 4
             

GP4

I have pain

0

1 2 3 4
             

GP5

I am bothered by side effects of treatment

0

1 2 3 4
             

GP6

I feel ill

0

1 2 3 4
             

GP7

I am forced to spend time in bed

0

1 2 3 4

 

 

EMOTIONAL WELL-BEING

Not at all

A little bit

Some what

Quite a bit

Very Much

             

GE1

I feel sad

0

1 2 3 4
             

GE2

I am dissatisfied with how I am coping with my illness

0

1 2 3 4
             

GE3

I am losing hope in the fight against my illness

0

1 2 3 4
             

GE4

I feel nervous

0

1 2 3 4
             

GE5

I worry about dying

0

1 2 3 4
             

GE6

I worry that my condition will get worse

0

1 2 3 4

 

 

 

SOCIAL/FAMILY WELL-BEING

Not at all

A little bit

Some what

Quite a bit

Very Much

             

GS1

I feel close to my friends

0

1 2 3 4
             

GS2

I get emotional support from my family

0

1 2 3 4
             

GS3

I get support from my friends

0

1 2 3 4
             

GS4

My family has accepted my illness

0

1 2 3 4
             

GS5

I am satisfied with family communication about my illness

0

1 2 3 4
             
GS6 I feel close to my partner (or the person who is my main support)

0

1 2 3 4
             

Q1

Regardless of your current sexual activity, please answer the following question. If you prefer not to answer it, please check this box and go to the next section.

I am satisfied with my sex life

0

1 2 3 4

 

 

 

FUNCTIONAL WELL-BEING

Not at all

A little bit

Some what

Quite a bit

Very Much

             

GF1

I am able to work (include work at home)

0

1 2 3 4
             

GF2

My work (include work at home) is fulfilling

0

1 2 3 4
             

GF3

I am able to enjoy life

0

1 2 3 4
             

GF4

I have accepted my illness

0

1 2 3 4
             

GF5

I am sleeping well

0

1 2 3 4
             

GF6

I am enjoying the things I usually do for fun

0

1 2 3 4
             

GF7

I am content with the quality of my life right now

0

1 2 3 4

 

Global Quality of Life Scale

On a scale of 0 to 10, with 0 being such poor quality of life that it would not be worth continuing to live, and 10 being the best quality of life you have ever had, at what number would you rate your quality of life in the past day? in the past week? in the past month?

Pain Scale

On a scale of 0 to 10, 0 being no pain, and 10 being the worst pain you have ever had in your life, at what level is your pain at this moment?

Using the same scale, what has been your average pain level in the past 24 hours? the past week? the past month?

Would you say that your amount of pain medicine over the past month has

Increased? Decreased? Stayed the same?

Normal Weight Current Weight

Please list all medications you are currently taking:
Medications Dosage Condition Prescribed For