I. Pain and disturbing body sensations No pain and disturbing body sensations. Mild pain or disturbing body sensation that does not limit any activities (e.g., work, social, sexual, sleep). Moderate pain or disturbing body sensations that limits a few activities. Moderate to severe pain or disturbing body sensations that limits many activities.

II. Energy Very full of energy, lots of pep. Fairly energetic, no limitation of activities (e.g., work, social, sexual). Moderate reduction in energy or pep that limits some activities. Generally low energy or pep that limits some activities. No energy or pep at all. I feel drained, and many activities are limited.

III. Support from family and friends Most of the time feel supported by my spouse, family, and friends. A fair amount of the time feel supported by my spouse, family, and friends. Occasionally feel supported by my spouse, family, and friends. Rarely feel supported by my spouse, family, and friends.

IV. Communication with doctor (primary caregiver for prostate cancer, may be specialist or family doctor) Always able to express my concerns to my doctor and get all the information or advice I need. Most of the time, able to express my concerns to my doctor and get all the information or advice I need. Some of the time, able to express my concerns to my doctor and get all the information or advice I need. Rarely able to express my concerns to my doctor and get all the information or advice I need.

V. Emotional well-being Generally happy and free from worry, sadness, or frustration. A little worry, sadness, or frustration. Moderate worry, sadness, or frustration. Quite a bit of worry, sadness, or frustration. Extreme worry, sadness, or frustration.

VI. Urinary frequency (need to pass urine frequently during the day or night) and urgency (difficulty delaying urination after the urge is felt to urinate and ability to “hold it”) No urinary frequency or urgency. A little urinary frequency or urgency, does not interfere with sleep or other activities (e.g., work, social), Some urinary frequency or urgency that interferes with sleep or other activities, may need to plan ahead. Quite a bit of urinary frequency or urgency, need to be near a bathroom most of the time. Extreme urinary frequency or urgency, need to be near a bathroom always.

VII. Leaking urine/poor bladder control Never, under any circumstances leak urine or lose bladder control. On rare occasions, leak urine or lose bladder control, does not interfere with any activities (e.g., work, social, sexual, sleep). Occasionally leak urine or lose bladder control, interferes with a few activities. A moderate amount of the time, leak urine or lose bladder control, interferes with some activities. Most of the time, leak urine or have poor bladder control, interferes with many activities. Require a clamp, catheter, or collecting bag, because leaking urine or poor bladder control.

VIII. Sexual function (problems with achieving/maintaining an erection) Full erections sufficient for intercourse. Erections sufficient for intercourse, but some reduction in firmness. Erections sufficient for masturbation or foreplay only. Erections, but not firm enough for any sexual activity. No erections at all.

IX. Sexual interest/drive Normal amount of sexual drive and interest for you. A little decrease of sexual drive or interest for you. Moderate decrease of sexual drive or interest for you. Substantial decrease of sexual drive or interest for you. No sexual drive or interest.

X. Bowel problems: diarrhea, rectal discomfort (pain, burning or irritation), or constipation No diarrhea, rectal discomfort, or constipation. Occasionally have diarrhea, rectal discomfort, or constipation. Frequently have diarrhea, rectal discomfort, or constipation. Nearly always have diarrhea, rectal discomfort, or constipation.

Taken from Ku et al. Can Urol Assoc J 2009;3(6):445–52.