Emotional Impact (ASCQ)

Please respond to each question or statement by marking one box per row.

		Never	Rarely	Sometimes	Often	Always
EmotionalImpactQ5	In the past 7 days, how often did you feel completely alone because of your health problems?…………………………….	 5	 4	 3	 2	 1

EmotionalImpactQ6	In the past 7 days, how often did you think your life would be better if you were healthy? …………………………………..	 5	 4	 3	 2	 1

EmotionalImpactQ7	In the past 7 days, how often were you very worried that you would die soon? …………………………………………….	 5	 4	 3	 2	 1

EmotionalImpactQ8	In the past 7 days, how often were you depressed about your health problems? ……………………………………….	 5	 4	 3	 2	 1

EmotionalImpactQ11	In the past 7 days, how often did you feel completely hopeless because of your health? …………………………………….	 5	 4	 3	 2	 1

EmotionalImpactQ14	In the past 7 days, how often were you sad about your health problems? ….	 5	 4	 3	 2	 1

EmotionalImpactQ15	In the past 7 days, how often did you feel that sickle cell disease could take your life at any moment? …………………..	 5	 4	 3	 2	 1

EmotionalImpactQ17	In the past 7 days, how often were you very worried about needing to go to the hospital?…………………………………	 5	 4	 3	 2	 1

EmotionalImpactQ18	In the past 7 days, how often did you think your health problems were ruining your life? ……………………………..	 5	 4	 3	 2	 1

EmotionalImpactQ20	In the past 7 days, how often did you wish very much for your suffering to end?………………………………………………..	 5	 4	 3	 2	 1

Not at all			A little	Somewhat	Quite	Very
EmotionalImpactQ1	In the past 7 days, how hopeful did you feel about your health? ……………….	 1	 2	 3	 4	 5

EmotionalImpactQ2	In the past 7 days, how worried did you feel about your health? ……………….	 5	 4	 3	 2	 1

EmotionalImpactQ3	In the past 7 days, how different did you feel from others because of your health problems?………………………………	 5	 4	 3	 2	 1

EmotionalImpactQ4	In the past 7 days, how good did you feel about your health? ……………………..	 1	 2	 3	 4	 5

EmotionalImpactQ10	In the past 7 days, how sad did you feel because of your health? ………………	 5	 4	 3	 2	 1

EmotionalImpactQ12	In the past 7 days, how lonely did you feel because of your health problems? ..	 5	 4	 3	 2	 1

EmotionalImpactQ16	In the past 7 days, how depressed were you about your health problems?..	 5	 4	 3	 2	 1

EmotionalImpactQ19	In the past 7 days, how sad were you about your health problems ……………….	 5	 4	 3	 2	 1
	Not at all		A little bit	Somewhat	Quite a bit	Very much
EmotionalImpactQ9	In the past 7 days, how much did you worry about getting sick? ………………….	 5	 4	 3	 2	 1

EmotionalImpactQ13	In the past 7 days, how much did your health bother you? ……………………………	 5	 4	 3	 2	 1

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