Washing

1 very much 2 quite a bit 3 moderate 4 a little 5 not at all

2.Dressing

1 very much 2 quite a bit 3 moderate 4 a little 5 not at all

3.Eating

1 very much 2 quite a bit 3 moderate 4 a little 5 not at all

4.Do you feel limited in any way?

1 very much 2 quite a bit 3 moderately 4 a little 5 not at all

5.Were you short of breath?

1 very much 2 quite a bit 3 moderately 4 a little 5 not at all

6.Have you experienced any pain?

1 very much 2 quite a bit 3 moderate 4 a little 5 not at all

7.Current pain medication:

8.Is this medication sufficient?

9.Have you had trouble sleeping?

1 very much 2 quite a bit 3 moderate 4 a little 5 not at all

10.Are you tired during the day?

1 very much 2 quite a bit 3 moderately 4 a little 5 not at all

11.Have you had difficulty in concentrating on things, such as reading a newspaper or watching television?

1 very much 2 quite a bit 3 moderate 4 a little 5 not at all

12.Have you had difficulty remembering things?

1 very much 2 quite a bit 3 moderate 4 a little 5 not at all

13.Have you experienced a lack of appetite?

1 very much 2 quite a bit 3 moderate 4 a little 5 not at all

14.Have you experienced nausea?

1 very much 2 quite a bit 3 moderate 4 a little 5 not at all

15.Have you vomited at all?

1 very much 2 quite a bit 3 moderately 4 a little 5 not at all

16.Have you been constipated?

1 very much 2 quite a bit 3 moderately 4 a little 5 not at all

17.Have you had diarrhoea?

1 very much 2 quite a bit 3 moderate 4 a little 5 not at all

18.Do you feel frightened?

1 very much 2 quite a bit 3 moderately 4 a little 5 not at all

19.Do you worry?

1 very much 2 quite a bit 3 moderately 4 a little 5 not at all

20.Do you feel tense?

1 very much 2 quite a bit 3 moderately 4 a little 5 not at all

21.Do you have pain in your mouth?

1 very much 2 quite a bit 3 moderate 4 a little 5 not at all

22.Do you have soreness in your mouth?

1 very much 2 quite a bit 3 moderate 4 a little 5 not at all

23.Do you have a painful throat?

1 very much 2 quite a bit 3 moderate 4 a little 5 not at all

24.Do you have problems swallowing liquids?

1 very much 2 quite a bit 3 moderate 4 a little 5 not at all

25.Do you have problems swallowing pureed food?

1 very much 2 quite a bit 3 moderate 4 a little 5 not at all

26.Do you have problems swallowing solid food?

1 very much 2 quite a bit 3 moderate 4 a little 5 not at all

27.Have you choked when swallowing?

1 very much 2 quite a bit 3 sometimes 4 a little 5 not at all

28.Do you have a dry mouth?

1 very much 2 quite a bit 3 moderate 4 a little 5 not at all

29.Do you have problems with your sense of smell?

1 very much 2 quite a bit 3 moderate 4 a little 5 not at all

30.Do you have problems with your sense of taste?

1 very much 2 quite a bit 3 moderate 4 a little 5 not at all

31.Has your appearance bothered you?

1 very much 2 quite a bit 3 moderately 4 a little 5 not at all

32.Do you have trouble talking to other people?

1 very much 2 quite a bit 3 moderate 4 a little 5 not at all

33.Do you have trouble when receiving visitors?

1 very much 2 quite a bit 3 moderate 4 a little 5 not at all

34.Have you lost weight?

1 very much 2 quite a bit 3 moderately 4 a little 5 not at all

35.Have you gained weight?

1 very much 2 quite a bit 3 moderately 4 a little 5 not at all