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 a hearing aid

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 toothache 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 heartbeat, or other discomfort in the chest

An upset stomach, abdominal pain, nausea, heartburn, or vomiting

Difficulty with bowel movements, diarrhea, constipation, rectal bleeding, black tar-like stools, or rectal pain

Pain, burning, or blood in urine

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

Genital pain, itching, burning, abnormal discharge, 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 joints or muscles of the hands, 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 written/spoken words, or significant memory loss

Thoughts or images you could not get out of your mind

Took any medication including over-the-counter remedies

Stayed on a medically prescribed diet for health reasons

A loss of appetite or over-eating

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

Did not drive a motor vehicle or use public transportation because of health, or needed help to use them

Had trouble climbing stairs or inclines or walking off the curb

Avoided or had trouble walking, or walked more slowly than other people your age

Limped, or used a cane, crutches, or walker

Avoided or had trouble bending over, stooping, or kneeling

Had trouble lifting or carrying everyday objects (e.g., books, groceries)

Had any other limitations in physical movements

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

Spent all or most of the day in a wheelchair

If in a wheelchair, someone else controlled its movement

Needed help with personal care needs (e.g., eating, dressing, bathing, getting around home)

Avoided, needed help with, or were limited in doing usual activities (e.g., work, school, housekeeping)