Quality of Life. Questionnaire 3. 4 weeks after randomisation. Graag in laten vullen door geincludeerde patiënt METEX studie

Transcription

1 Patient registration label Quality of Life Questionnaire 3 4 weeks after randomisation Graag in laten vullen door geincludeerde patiënt Patient Identification Number Datum van invullen 1

2 SF-36 HEALTH SURVEY INSTRUCTIONS: This survey asks for your views about your health. This information will help keep track of how you feel end how well you are able to do your usual activities. Answer every question by marking the anser as indicated. If you are unsure about how to answer a question, please give the best answer you can. 1. In general how would you say your health is: Excellent... 1 Very good... 2 Good... 3 Fair... 4 Poor Compared to one year ago, how would you rate your health in general now? Much better now than one year ago... 1 Somewhat better now than one year ago... 2 About the same as one year ago... 3 Somewhat worse now than one year ago... 4 Much worse now than one year ago

3 3. The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much? (omcirkel één cijfer op elke regel) Activities a. Vigorous activities such as running, lifting heavy objects, participating in strenuous sports b. Moderate activities such as moving a table, pushing a vacuum cleaner, bowling, or playing golf Yes, Limited a lot Yes, Limtited a little No, not limited at all c. Lifting or carrying groceries d. Climbing several flights of stairs e. Climbing one flight of stairs f. Bending, kneeling, or stooping g. Walking more than a mile h. Walking several blocks i. Walking one block j. Bathing or dressing yourself During the past week, have you had any of the following problems with your work or other regular daily activities as a result of your physical health? (circle one number on each line) YES NO a. Cut down on the amount of you spent on work or other activities 1 2 b. Accoplished less than you would like 1 2 c. Were limited in the kind of work or other activities 1 2 d. Had difficulty performing the work or other activities ( for example, it took extra effort) 1 2 3

4 5. During the past week, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)? (circle one number on each line) YES NO a. Cut down the amount of you spent on work or other activities 1 2 b. Accomplished less than you would like 1 2 c. Didn t do work or other activities as carefully as usual During the past week, to what extent has your physical health or emotional problems interfered with your normal social activities with family, friends, neighbors, or groups? (omcirkel één cijfer) Not at all Slightly.. 2 Moderately Quite a bit Extremely How much bodily pain have you had during the past week? None Very mild Mild Moderate Severe Very severe

5 8. During the past week, how much did pain interfere with your normal work (including both work outside the home and housework)? Not at all A little bit Moderately Quite a bit Extremely These questions are about how things have been with you during the past week. For each question, please give the one answer that comes closest to the way you have been feeling. How much of the during the last week: (circle one number on each line) All of the Most of the A good bit of the Some of the A little of the None of the a. Did you feel full of pep? b. Have you been a very nervous person? c. Have you felt so down in the dumps that nothing could cheer you up? d. Have you felt calm and peaceful? e. Did you have a lot of energy? f. Have you felt downhearted and blue? g. Did you feel worn out? h. Have you been a happy person? i. Did you feel tired?

6 10. During the past week, how much of the has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)? All of the Most of the Some of the A little of the... 4 None of the How TRUE or FALSE is each of the following statements for you? (circle one number on each line) a. I seem to get sich a little easier than other people Definitely True Mostly True Don t know Mostly False Definitely False b. I am as healthy as anybody I know c. I expect my health to get worse d. My health is excellent

7 In this questionnaire you will be asked about your symptoms. Would you please, for all symptoms mentioned, indicate to what extent you have been bothered by it, by circling the answer most applicable to you. The questions are related to the past week. Example: Have you been bothered, during the past week, by Headaches not at all a little quite a bit very much Have you been bothered, during the past week, by Lack of appetite not at all a little quite a bit very much Tiredness not at all a little quite a bit very much Skin rash/irritation not at all a little quite a bit very much Lack of energy not at all a little quite a bit very much Redness of eyes not at all a little quite a bit very much Nausea not at all a little quite a bit very much Difficulty sleeping not at all a little quite a bit very much Headache not at all a little quite a bit very much Vomiting not at all a little quite a bit very much Dizziness not at all a little quite a bit very much Sore mouth/ pain when swallowing not at all a little quite a bit very much Decreased sexual interest not at all a little quite a bit very much Heartburn/belching not at all a little quite a bit very much Shivering not at all a little quite a bit very much Tingling hands or feet not at all a little quite a bit very much Abdominal aches not at all a little quite a bit very much Burning/ sore eyes not at all a little quite a bit very much Hypersensitivity to sunlight not at all a little quite a bit very much Shortness of breath not at all a little quite a bit very much Dry mouth not at all a little quite a bit very much Diarrhoea not at all a little quite a bit very much Constipation not at all a little quite a bit very much 7

8 This questionnaire is designed to help your doctor to know how you feel. Read each item and place a firm tick in the box opposite the reply which comes closest to how you have been feeling in the past week. 1. I feel tense or wound up : Most of the A lot of the Time to, occasionally 2. I still enjoy the things I used to enjoy: Definitely as much Not quite so much Only a little Hardly at all 3. I get a sort of frightened feeling as if something awful is about to happen: very definitely and quite badly Yes, but not too badly A little, but it doesn t worry me 4. I can laugh and see the funny side of things: As much as I always could Not quite so much now Definitely not so much now 5. Worrying thoughts go through my mind: A great deal of the A lot of the From to but not too often Only occasionally 6. I feel cheerful: Not often Somes Most of the 7. I can sit at ease and feel relaxed: Definitely Usually Not often 8

9 8. I feel as if I am slowed down: Nearly all the Very often Somes 9. I get a sort of frightened feeling like butterflies in the stomach Occasionally Quite often Very often 10. I have lost interest in my appearance: Definitely I don t take so much care as I should I may not take quite as much care I take just as much care as ever 11. I feel restless as if I have to be on the move: Very much indeed Quite a lot Not very much 12. I look forward with enjoyment to things: As much as ever I did Rather less than I used to Definitely less than I used to Hardly at all 13. I get sudden feelings of panic: Very often indeed Quite often Not very often 14. I can enjoy a good book or radio or TV programme: Often Somes Not often Very seldom 9