Quality of Well-Being Scale Self-Administered – QWB-SA

Blindness, or severely impaired vision in both eyes

Blindness or severely impaired vision in only one eye

Speech problems such as stuttering, or being unable to speak clearly

Missing or paralyzed hands, feet, arms or legs

Missing or paralyzed fingers or toes

Any deformity of the face, fingers, hand/arm, foot/leg, or back

General fatigue, tiredness or weakness

A problem with unwanted weight gain or weight loss

A problem with being under or overweight

Problems chewing your food adequately

Any hearing loss or deafness

Any noticeable skin problems (e.g., bad acne, large burns or scars)

Eczema or burning/itching rash

Use of dentures

Use of eye glasses or contact lenses

Use of hearing aide

Any problems with your vision not corrected with glasses or contact lenses

Any eye pain, irritation, discharge, or excessive sensitivity to light

A headache

Dizziness, earache or ringing in your ears

Difficulty hearing or discharge or bleeding from an ear

Stuffy or runny nose or bleeding from the nose

A sore throat, difficulty swallowing, or hoarse voice

A tooth ache or jaw pain

Sore or bleeding lips, tongue, or gums

Coughing or wheezing

Shortness of breath or difficulty breathing

Chest pain, pressure, palpitations, fast or skipped heart beat or other discomfort in the chest

An upset stomach, abdominal pain, nausea, heart burn or vomiting

Difficulty with bowel movements, diarrhea, constipation, rectal bleeding, black tar-like stools, or any pain or discomfort in the rectal area

Pain, burning, or blood in urine

Loss of bladder control, frequent night-time urination or difficulty with urination

Genital pain, itching, burning, or abnormal discharge, or pelvic cramping or abnormal bleeding

Broken arm, wrist, foot, leg, or other broken bone (other than in back)

Pain, stiffness, cramps, weakness or numbness in the neck or back

Pain, stiffness, cramps, weakness or numbness in the hips or sides

Pain, stiffness, cramps, weakness or numbness in any of the joints or muscles of the hand, feet, arms or legs

Swelling of ankles, hands, feet, or abdomen

Fever, chills, or sweats

Loss of consciousness, fainting, or seizures

Difficulty with your balance, standing or walking

Trouble falling asleep or staying asleep

Spells of feeling nervous or shaky

Spells of feeling upset, downhearted, or blue

Excessive worry or anxiety

Feelings that you had little or no control over events in your life

Feelings of being lonely or isolated

Feelings of frustration, irritation or close to losing your temper

A hangover

Any decrease of sexual interest or performance

Confusion, difficulty understanding the written or spoken word, or significant memory loss

Thoughts or images you could not get out of your mind

Take any medication including over-the-counter remedies

To stay on a medically prescribed diet for health reasons

A loss of appetite or over-eating

Spend any part of the day or night as a patient in a hospital, nursing home, or rehabilitation center

Either not drive a motor vehicle or not use public transportation because of your health or need help from another person to use

Have trouble climbing stairs or inclines or walking off the curb

Avoid or have trouble walking, or walk more slowly than other people your age

Limp, use a cane, crutches or walker

Avoid or have trouble bending over, stooping or kneeling

Have any trouble lifting or carrying everyday objects such as books, a briefcase or groceries

Have any other limitations in physical movements

Spend all or most of the day in a bed, chair or couch

Spend all or most of the day in a wheelchair

If in wheelchair, someone else controlled its movement

Need help with your personal care needs, such as eating, dressing, bathing, or getting around your home

Avoid, need help with, or were limited in doing some of your usual activities, such as work, school, or housekeeping