Table 8.
Twenty-four items and one alternative remained as candidates for the questionnaire
| C-1. Can you fasten the front buttons of your blouse or shirt using both hands? |
| 1) I can do it without difficulty. |
| 2) I can do it if I spend time. |
| 3) I cannot do it. |
| 0) I am not sure. |
| C-7. Can you eat a meal using a spoon or a fork with your right hand? |
| 1) I can do it without difficulty. |
| 2) I can do it if I spend time. |
| 3) I cannot do it. |
| 0) I am not sure. |
| C-13. Can you raise your right arm? |
| 1) I can raise it straight upward. |
| 2) I can raise it upward when flexed a little. |
| 3) I can raise it halfway (up to shoulder level). |
| 4) I cannot raise it. |
| C-18. Can you walk on a flat surface? |
| 1) I can do it without difficulty. |
| 2) I can do it slowly. |
| 3) I can do it with support (of a handrail, a stick, or a walker). |
| 4) I can do it only slowly even with support. |
| 5) I cannot do it. |
| 0) I am not sure. |
| C-21. Can you stand on your right leg without the support of your hand? |
| 1) I can do it for more than 10 seconds. |
| 2) I can do it for less than 10 seconds. |
| 3) I can hardly do it. |
| 0) I am not sure. |
| C-28. Do you have urinary incontinence? |
| 1) No. |
| 2) I have it when I sneeze or strain myself. |
| 3) I have it when I do not release urine over a period of more than two hours. |
| 4) Frequently. |
| 5) Always. |
| C-30. How often do you go to the bathroom (to void urine) at night? |
| 1) Hardly ever. |
| 2) Once or twice. |
| 3) Three times or more. |
| C-31. Do you have a feeling of residual urine even after voiding of urine (urination)? |
| 1) I rarely have such a feeling. |
| 2) I sometimes have such a feeling, and sometimes not. |
| 3) I usually have such a feeling. |
| 0) I am not sure. |
| C-32. Can you void urine immediately in the toilet? |
| 1) I almost always can do it immediately. |
| 2) I sometimes can do it immediately, and sometimes not. |
| 3) I usually cannot do it immediately. |
| 0) I am not sure. |
| C-35. While in the sitting position, can you look up at the ceiling by drawing your head directly backward? |
| 1) I can do it without difficulty. |
| 2) I can do it with some effort. |
| 3) I cannot do it. |
| C-37. Can you drink a glass of water in one gulp? |
| 1) I can do it without difficulty. |
| 2) I can do it with some effort. |
| 3) I cannot do it. |
| 0) I am not sure. |
| C-38. Can you see your feet when you walk down the stairs? |
| 1) I can do it without difficulty. |
| 2) I can do it with some effort. |
| 3) I cannot do it. |
| 0) I am not sure. |
| C-41. Can you turn your head when you back your car? |
| 1) I can do it without difficulty. |
| 2) I can do it with some effort. |
| 3) I cannot do it. |
| 0) I am not sure. I do not drive a car/I do not drive these days. |
| C-41-2. Alternative question |
| While in the sitting position, can you turn your head toward the person who is seated behind you and speak to him/her while looking him/her in the face? |
| 1) I cannot do it. |
| 2) I can do it with some effort. |
| 3) I can do it without difficulty. |
| QOL-1. What is your present health condition? |
| 1) Excellent |
| 2) Very good |
| 3) Good |
| 4) Not very good |
| 5) Poor |
| 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. |
| 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 |
| 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.) |
| 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. |
| 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). |
| 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 |
| QOL-11. Circle the item number of each of the following topics that best applies to your condition. |
| 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. |