Not at all (n) | A little (n) | Quite a bit (n) | Very much (n) | ||||
---|---|---|---|---|---|---|---|
1. Do you have any trouble doing strenuous activities like carrying a heavy shopping bag or a suitcase? | 6 | 8 | 5 | 2 | |||
2. Do you have any trouble taking a long walk? | 7 | 4 | 5 | 5 | |||
3. Do you have any trouble taking a short walk? | 14 | 3 | 2 | 2 | |||
4. Do you need to stay in bed or a chair during the day? | 5 | 6 | 7 | 3 | |||
5. Do you need help with eating, dressing, washing yourself or using the toilet? | 21 | 0 | 0 | 0 | |||
During the past week: | |||||||
6. Were you limited in doing either your work or other daily activities? | 4 | 9 | 4 | 4 | |||
7. Were you limited in pursuing your hobbies or other leisure time activities? | 5 | 6 | 4 | 5 | |||
8. Were you short of breath? | 14 | 1 | 6 | 0 | |||
9. Have you had pain? | 6 | 5 | 8 | 2 | |||
10. Did you need to rest? | 1 | 9 | 8 | 3 | |||
11. Have you had trouble sleeping? | 11 | 5 | 3 | 2 | |||
12. Have you felt weak? | 5 | 8 | 5 | 3 | |||
13. Have you lacked appetite? | 10 | 6 | 3 | 2 | |||
14. Have you felt nauseated? | 15 | 4 | 2 | 0 | |||
15. Have you vomited? | 17 | 3 | 0 | 0 | |||
16. Have you been constipated? | 8 | 8 | 2 | 3 | |||
17. Have you had diarrhea? | 14 | 4 | 2 | 1 | |||
18. Were you tired? | 3 | 9 | 6 | 3 | |||
19. Did pain interfere with your daily activities? | 7 | 5 | 5 | 4 | |||
20. Have you had difficulty in concentrating on things, like reading a newspaper or watching television? | 18 | 2 | 1 | 0 | |||
21. Did you feel tense? | 14 | 5 | 1 | 1 | |||
22. Did you worry? | 11 | 8 | 1 | 1 | |||
23. Did you feel irritable? | 13 | 5 | 3 | 0 | |||
24. Did you feel depressed? | 11 | 7 | 2 | 0 | |||
25. Have you had difficulty remembering things? | 13 | 5 | 3 | 0 | |||
26. Has your physical condition or medical treatment interfered with your family life? | 10 | 4 | 6 | 1 | |||
27. Has your physical condition or medical treatment interfered with your social activities? | 6 | 7 | 6 | 2 | |||
28. Has your physical condition or medical treatment caused you financial difficulties? | 20 | 1 | 0 | 0 | |||
Very poor | Excell- ent | ||||||
1 | 2 | 3 | 4 | 5 | 6 | 7 | |
29. How would you rate your overall health during the past week? (n) | 0 | 1 | 7 | 5 | 2 | 4 | 2 |
30. How would you rate your overall quality of life during the past week? (n) | 0 | 1 | 4 | 5 | 4 | 5 | 2 |