Quality of Well-Being Scale

Mobility Scale (MOB)
  No limitations for health reasons
  Did not drive a car‚ health related; did not ride in a car as usual for age (younger than 15 yr)‚ health related‚ and/or did not use public transportation‚ health related; or had or would have used more help than usual for age to use public transportation‚ health related
  In hospital‚ health related
Physical Activity Scale (PAC)
  No limitations for health reasons
  In wheelchair‚ moved or controlled movement of wheelchair without help from someone else; or had trouble or did not try to lift‚ stoop‚ bend over‚ or use stairs or inclines‚ health related; and/or had any other physical limitation in walking‚ or did not try to walk as far as or as fast as others the same age are able‚ health related
  In wheelchair‚ did not move or control the movement of wheelchair without help from someone else‚ or in bed‚ chair‚ or couch for most or all of the day‚ health related
Social Activity Scale (SAC)
  No limitations for health reasons
  Limited in other (e.g. recreational) role activity‚ health related
  Limited in major (primary) role activity‚ health related
  Performed no major role activity‚ health related‚ but did perform self-care activities
  Performed no major role activity‚ health related‚ and did not perform or had more help than usual in performance of one or more self-care activities‚ health related
CPX description
1.    Death [not on respondent’s card]
2.    Loss of consciousness such as seizure (fits)‚ fainting‚ or coma (out cold or knocked out)
3.    Burn over large areas of face‚ body‚ arms‚ or legs
4.    Pain‚ bleeding‚ itching‚ or disch‎arge (drainage) from sexual organs—does not include normal menstrual bleeding
5.    Trouble learning‚ remembering‚ or thinking clearly
6.    Any combination of one or more hands‚ feet‚ arms‚ or legs either missing‚ deformed (crooked)‚ paralyzed (unable to move)‚ or broken—includes wearing artificial limbs or braces
7.    Pain‚ stiffness‚ weakness‚ numbness‚ or other discomfort in chest‚ stomach (including hernia or rupture)‚ side‚ neck‚ back‚ hips‚ or any joints or hands‚ feet‚ arms‚ or legs
8.    Pain‚ burning‚ bleeding‚ itching‚ or other difficulty with rectum‚ bowel movements‚ or urination (passing water)
9.    Sick or upset stomach‚ vomiting or loose bowel movement‚ with or without chills‚ or aching all over
10.General tiredness‚ weakness‚ or weight loss
11.Cough‚ wheezing or shortness of breath‚ with or without fever‚ chills‚ or aching all over
12.Spells of feeling upset‚ being depressed‚ or of crying
13.Headache‚ or dizziness‚ or ringing in ears‚ or spells of feeling hot‚ nervous or shaky
14.Burning or itching rash on large areas of face‚ body‚ arms‚ or legs
15.Trouble talking‚ such as lisp‚ stuttering‚ hoarseness‚ or being unable to speak
16.Pain or discomfort in one or both eyes (such as burning or itching) or any trouble seeing after correction
17.Overweight for age and height or skin defect of face‚ body‚ arms‚ or legs‚ such as scars‚ pimples‚ warts‚ bruises or changes in color
18.Pain in ear‚ tooth‚ jaw‚ throat‚ lips‚ tongue; several missing or crooked permanent teeth—includes wearing bridges or false teeth
19.Took medication or stayed on a prescribed diet for health reasons
20.Wore eyeglasses or contact lenses
21.Breathing smog or unpleasant air
22.No symptoms or problems [not on respondent’s card]
23.Standard symptom/problem
24.Trouble sleeping
25.Intoxication
26.Problems with sexual interest or performance
27.Excessive worry or anxiety
 
Quality of Well Being Self-Administered (QWB-SA) Scale
Symptoms (CPX)
Yes; No
·         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 (i.e.‚ bad acne‚ large burns or scars)
·         eczema or burning/itching rash
health aides used:
·         dentures
·         eye glasses or contact lenses
·         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 (does not include normal menstruation).
·         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 (aspirin/Tylenol‚ allergy medications‚ insulin‚ hormones‚ estrogen‚ thyroid‚ prednisone)
·         to stay on a medically prescribed diet for health reasons
·         a loss of appetite or over-eating
Mobility
·         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
Physical Activity
·         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
Social & Self-care activity
·         need help with your personal care needs‚ such as eating‚ dressing‚ bathing‚ or getting around our home
·         avoid‚ need help with‚ or were limited in doing some of your usual activities‚ such as work‚ school‚ or housekeeping?
 
 

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Sieber‚ William J.‚ Groessl‚ Erik J.‚ David‚ Kristin M.‚ Ganiats‚ Theodore G.‚ Kaplan‚ Robert M. (2008). Quality of Well Being Self-Administered (QWB-SA) Scale: User’s Manual. Health Services Research Center University of California‚ San Diego.