Not at All 0	A Little 1	Somewhat 2	Quiet a Bit 3	Very Much 4
1	I have difficulties with falling asleep	0	1	2	3	4
2	I sleep poorly	0	1	2	3	4
3	I wake up during the night	0	1	2	3	4
4	My muscles are aching	0	1	2	3	4
5	My joints are aching	0	1	2	3	4
6	My legs are aching	0	1	2	3	4
7	There is a burning ache in my feet	0	1	2	3	4
8	There is a numb and stabbing feeling in my feet	0	1	2	3	4
9	I am physically tired	0	1	2	3	4
10	I have no energy	0	1	2	3	4
11	I feel lazy and listless	0	1	2	3	4
12	I have difficulties to remember	0	1	2	3	4
13	I find it hard to concentrate	0	1	2	3	4
14	Due to my physical condition I can’t take a bath or shower	0	1	2	3	4
15	Due to my physical condition I can’t get dressed by myself	0	1	2	3	4
16	Due to my physical condition I can’t buy food by myself	0	1	2	3	4
17	I feel irritated	0	1	2	3	4
18	I feel angry	0	1	2	3	4
19	I worry about not being able to keep my job due to my health condition	0	1	2	3	4
20	I worry about my economy due to my health condition	0	1	2	3	4
21	I’m breathless	0	1	2	3	4
22	I need to rest because I am breathless	0	1	2	3	4
23	I’m swollen	0	1	2	3	4
24	I feel nauseous	0	1	2	3	4
25	I have oral fungus	0	1	2	3	4
26	I have oral herpes	0	1	2	3	4
27	I have increased appetite for food	0	1	2	3	4
28	I have decreased appetite for food	0	1	2	3	4
29	I have dyspepsia	0	1	2	3	4
30	I’m constipated	0	1	2	3	4
31	I have diarrhea	0	1	2	3	4
32	My skin is itching	0	1	2	3	4
33	I have headache	0	1	2	3	4
34	There is a burning pain in my hands	0	1	2	3	4
35	There is a numb and stabbing pain in my hands	0	1	2	3	4
36	My hands are trembling	0	1	2	3	4
37	I feel dizzy	0	1	2	3	4
38	I feel sad	0	1	2	3	4
39	My looks makes me embarrassed	0	1	2	3	4
40	My libido is decreased	0	1	2	3	4