Table 2.
A questionnaire to assess health-related quality of life (QOL)
| The following are questions on your daily life during the last week (unless otherwise specified). For each question, circle one of the items numbered 1–5 that best describes your condition. |
| QOL-1 What is your present health condition? |
| 1) Excellent |
| 2) Very good |
| 3) Good |
| 4) Not very good |
| 5) Poor |
| QOL-2 What is your present health condition as compared with that of a year ago? |
| 1) Much better |
| 2) A little bit better |
| 3) Almost the same |
| 4) Not as good |
| 5) Much worse |
| QOL-3 The following are ordinary daily activities. Please indicate if you have difficulty doing them because of your poor health condition and, if so, how difficult you think it is to do them. Circle the item number that most applies. |
| 1. Engaging in hard activities |
| (Such as running fast, lifting a heavy object, doing intense exercise) |
| 1) I have great difficulty |
| 2) I have some difficulty |
| 3) I do not have any difficulty |
| 2. Engaging in moderate activities |
| (Such as cleaning the house, taking care of the yard, taking a one- or two-hour walk) |
| 1) I have great difficulty |
| 2) I have some difficulty |
| 3) I do not have any difficulty |
| 3. Lifting or carrying moderately heavy objects |
| (Such as a shopping bag) |
| 1) I have great difficulty |
| 2) I have some difficulty |
| 3) I do not have any difficulty |
| 4. Climbing the stairs to higher floors |
| 1) I have great difficulty |
| 2) I have some difficulty |
| 3) I do not have any difficulty |
| 5. Climbing the stairs to one floor above |
| 1) I have great difficulty |
| 2) I have some difficulty |
| 3) I do not have any difficulty |
| 6. Bending forward, kneeling, and stooping |
| 1) I have great difficulty |
| 2) I have some difficulty |
| 3) I do not have any difficulty |
| 7. Walking a kilometer |
| 1) I have great difficulty |
| 2) I have some difficulty |
| 3) I do not have any difficulty |
| 8. Walking a few hundred meters |
| 1) I have great difficulty |
| 2) I have some difficulty |
| 3) I do not have any difficulty |
| 9. Walking a hundred meters |
| 1) I have great difficulty |
| 2) I have some difficulty |
| 3) I do not have any difficulty |
| 10. Taking a bath or changing clothes without the support of others |
| 1) I have great difficulty |
| 2) I have some difficulty |
| 3) I do not have any difficulty |
| QOL-4 When you engaged in your work or daily activities (including housework) during the last month, did you have any of the problems listed below because of your physical condition? (Circle the item number in each topic that best applies.) |
| 1. I decreased the number of hours of working or daily activities. |
| 1) Always |
| 2) Almost always |
| 3) Sometimes |
| 4) Rarely |
| 5) Not at all |
| 2. I could not do my work or daily activities as well as I expected. |
| 1) Always |
| 2) Almost always |
| 3) Sometimes |
| 4) Rarely |
| 5) I was able to do my work or daily activities as well as I expected. |
| 3. I could not do some kinds of work or daily activities. |
| 1) Always |
| 2) Almost always |
| 3) Sometimes |
| 4) Rarely |
| 5) I was able to do any kind of work or daily activities. |
| 4. I had difficulty in engaging in my work or daily activities (e.g., I needed more effort to do it). |
| 1) Always |
| 2) Almost always |
| 3) Sometimes |
| 4) Rarely |
| 5) Not at all |
| QOL-5 When you engaged in your work or daily activities (including housework) during the last month, did you have any of the problems listed below because of psychological reasons? (Circle the item number in each topic that best applies.) |
| 1. I decreased the number of hours of working or daily activities. |
| 1) Always |
| 2) Almost always |
| 3) Sometimes |
| 4) Rarely |
| 5) Not at all |
| 2. I could not do my work or daily activities as well as I would like. |
| 1) Always |
| 2) Almost always |
| 3) Sometimes |
| 4) Rarely |
| 5) I was able to do my work or daily activities as well as I expected. |
| 3. I could not concentrate on my work or daily activities as hard as I can normally. |
| 1) Always |
| 2) Almost always |
| 3) Sometimes |
| 4) Rarely |
| 5) I was able to concentrate on my work or daily activities as hard as I can. |
| QOL-6 How severely were your relations with your family, friends, neighbors, and other acquaintances hindered because of physical or psychological reasons? |
| 1) Not at all |
| 2) A little |
| 3) Slightly |
| 4) Fairly |
| 5) Greatly |
| QOL-7 How severe was your pain during the last month? |
| 1) None |
| 2) Very mild |
| 3) Mild |
| 4) Moderate |
| 5) Severe |
| 6) Very severe |
| QOL-8 How severely was your work (including housework) hindered during the last month because of the pain? |
| 1) Not at all |
| 2) A little |
| 3) Slightly |
| 4) Fairly |
| 5) Greatly |
| QOL-9 The following are questions about your feelings during the last month (circle the item number of each question that best applies). |
| 1. Were you full of good spirits? |
| 1) Always |
| 2) Almost always |
| 3) Sometimes |
| 4) Rarely |
| 5) Not at all |
| 2. Were you rather nervous? |
| 1) Always |
| 2) Almost always |
| 3) Sometimes |
| 4) Rarely |
| 5) Not at all |
| 3. Were you desperately depressed? |
| 1) Always |
| 2) Almost always |
| 3) Sometimes |
| 4) Rarely |
| 5) Not at all |
| 4. Were you comfortable and peaceful? |
| 1) Always |
| 2) Almost always |
| 3) Sometimes |
| 4) Rarely |
| 5) Not at all |
| 5. Were you full of physical power and life? |
| 1) Always |
| 2) Almost always |
| 3) Sometimes |
| 4) Rarely |
| 5) Not at all |
| 6. Were you discouraged and depressed? |
| 1) Always |
| 2) Almost always |
| 3) Sometimes |
| 4) Rarely |
| 5) Not at all |
| 7. Were you exhausted? |
| 1) Always |
| 2) Almost always |
| 3) Sometimes |
| 4) Rarely |
| 5) Not at all |
| 8. Did you feel pleasant? |
| 1) Always |
| 2) Almost always |
| 3) Sometimes |
| 4) Rarely |
| 5) Not at all |
| 9. Did you feel tired? |
| 1) Always |
| 2) Almost always |
| 3) Sometimes |
| 4) Rarely |
| 5) Not at all |
| QOL-10 During the last month, how often were your relations with other people (for example, visiting your friends or relatives) hindered because of physical or psychological reasons? |
| 1) Always |
| 2) Almost always |
| 3) Sometimes |
| 4) Rarely |
| 5) Never |
| QOL-11 Circle the item number of each of the following topics that best applies to your condition. |
| 1. I think I am more likely to become ill than other people. |
| 1) Completely yes. |
| 2) Almost yes. |
| 3) I am not sure. |
| 4) I hardly think so. |
| 5) I do not think so. |
| 2. I am in decent health. |
| 1) Completely yes. |
| 2) Almost yes. |
| 3) I am not sure. |
| 4) I hardly think so. |
| 5) I do not think so. |
| 3. I feel my health will get worse. |
| 1) Completely yes. |
| 2) Almost yes. |
| 3) I am not sure. |
| 4) I hardly think so. |
| 5) I do not think so. |
| 4. My health condition is excellent. |
| 1) Completely yes. |
| 2) Almost yes. |
| 3) I am not sure. |
| 4) I hardly think so. |
| 5) I do not think so. |