1. Do you have any trouble doing strenuous activities‚ like carrying a heavy shopping bag or a suitcase?
2. Do you have any trouble taking a long walk?
3. Do you have any trouble taking a short walk outside of the house?
4. Do you need to stay in bed or a chair during the day?
5. Do you need help with eating‚ dressing‚ washing yourself or using the toilet?
During the past week:
6. Were you limited in doing either your work or other daily activities?
7. Were you limited in pursuing your hobbies or other leisure time activities?
8. Were you short of breath?
9. Have you had pain?
10.Did you need to rest?
11.Have you had trouble sleeping?
12.Have you felt weak?
13.Have you lacked appetite?
14.Have you felt nauseated?
15.Have you vomited?
16.Have you been constipated?
17.Have you had diarrhea?
18.Were you tired?
19.Did pain interfere with your daily activities?
20.Have you had difficulty in concentrating on things‚ like reading a newspaper or watching television?
21.Did you feel tense?
22.Did you worry?
23.Did you feel irritable?
24.Did you feel depressed?
25.Have you had difficulty remembering things?
26.Has your physical condition or medical treatment interfered with your family life?
27.Has your physical condition or medical treatment interfered with your social activities?
28.Has your physical condition or medical treatment caused you financial difficulties?
For the following questions please circle the number between 1 and 7 that best applies to you
29.How would you rate your overall health during the past week?
Very poor 1 2 3 4 5 6 7 Excellent
30.How would you rate your overall quality of life during the past week?
Very poor 1 2 3 4 5 6 7 Excellent
Physical (0.54- 0.80)‚ role (0.52-0.88)‚ emotional (0.73- 0.90)‚ cognitive (0.51- 0.73)‚ social (0.68- 0.86)‚ global (0.82- 0.89)‚ fatigue (0.77- 0.89)‚ nausea (0.50- 0.86) and pain (0.76- 0.89)
(1) Not at All‚ (2) A Little‚ (3) Quite a Bit‚ (4) Very Much
physical function (items 1-5)‚ role function (items 6 and 7)‚ cognitive function (items 20 and 25)‚ emotional function(items 21 to 24)‚ social function (items 26and 27)‚ The symptom scales include fatigue(items 10‚ 12‚ and 18)‚ nausea (items 14 and15)‚ and pain (items 9 and 19)‚ global QoLscale (items 29 and 30)‚ dyspnea (item 8)‚ sleep disturbance (item 11)‚ appetite loss (item 13)‚ constipation (item 16)‚ diarrhea (item 17)‚ financial impact of cancer (item 28).
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