Disease*
General
At least ten questions or choices from a table or pop-up list about personal history of disease (similar to forms filled out by new patients in doctor's offices?)
Diagnosis
What is the main kind of [primary diagnosis] that you have?
How many years have you had [this primary disease]?
How long has it been since you first learned your diagnosis?
Diagnosis of interest
Have you had surgery in the past month? If so, what kind?
My illness is severe (agree or disagree).
Looking toward the future, I feel certain that my [illness] will get better (agree or disagree).
I worry about the long term effects of this illness on my health (agree or disagree).
I worry that I might die from this illness (agree or disagree).
Other illness
Is your health currently affected by any of the following medical problems?
Have you had surgery in the past month [for this other
illness]? If so, what kind?
[My other current] illness is severe (agree or disagree).
Looking toward the future, I feel certain that my [other current illness] will get better (agree or disagree).
I worry about the long term effects of this [other current] illness on my health (agree or disagree).
I worry that I might die from this [other current] illness (agrees or disagrees).
Genetic Endowment
General medical facts
What is your age?
What is your sex?
What is your race?
Diagnosis of interest
Questions about family history of illness in question (first and second generation; minimum of six questions).
Other illness
Questions about family history of other illness mentions in "Other illness" section of "Disease" survey component. (A minimum of 6x questions, where x is the number of other illnesses presently suffered by the patient.)
Pain
General
How often do you suffer (physical) pain?
Throughout our lives, most of us have had pain from time to time (such as minor headaches, sprains, and toothaches).. Have you had pain other than these everyday kinds of pain during the last week? Questions about history with pain (Tie to responses to "General" questions under "Disease;" a minimum of xy questions, where x is the number of diseases in the patient's history, and y is the number of questions about general pain.)
Diagnosis of Interest
History
Have you ever had pain due to your present disease?
When you first received your diagnosis, was pain one of your symptoms?
How much trouble or distress have you had as a result of pain or soreness during the last four weeks?
Throughout our lives, most of us have had pain from time to time (such as minor headaches, sprains, and toothaches). [Has the disease in question caused anything] other than these everyday kinds of pain during the last week?
Experience and perception Symptoms
Location
On the diagram, shade in the areas where you
feel pain. Put an X on the area that hurts the most.
Intensity
Please rate your pain by circling the one number that best describes your pain at its worst in the last week (0 "No Pain" - 10 "Pain as bad as you can imagine").
Please rate your pain by circling the one number that best describes your pain at its least in the last week (0 "No Pain" - 10 "Pain as bad as you can imagine").
Please rate your pain by circling the one number that best describes your pain on average (0 "No Pain" - 10 "Pain as bad as you can imagine").
Please rate your pain by circling the one number that tells how much pain you have right now (0 "No Pain" - 10 "Pain as bad as you can imagine
Character
For each of the following words, check Yes or No if that adjective applies to your pain (15 words from MPQ follow). (The equivalent of 15 questions)
Do you ever find yourself praying while you are in pain?(Link to "Spiritual and Philosophical Beliefs in "Well-Being Component.)
Do you ever repeat words or numbers when you are in pain?
If yes, what words or numbers? Do you think of your pain as having a color?
Which color?
Do you think of your pain as having a shape? What shape? (Could offer a menu of shapes, or the capacity to produce a shape with simple computer drawing tools.)
Does it seem that your pain ever moves in a pattern or in a direction?
(flickering, quivering, pulsing, throbbing, beating, pounding, jumping, flashing, shooting)
Where does it move? (offer possibility to click or drag on a diagram.)
Does the pain ever make you think of a fire or something hot?
(hot, burning, scalding, searing)
Where is it? (Offer a diagram)
Does it ever make you think of water? A river? A lake? A dam? A block of ice?
Where is it? (Offer a diagram)
Does the pain ever make you think of something like a rock or a mountain?
Where is it? (Offer a diagram)
Does it feel like gravel?
Where is it? (Offer a diagram)
Does it ever remind you of a tree branch or a root or something from a plant?
Which one?
Where is it? (Offer a diagram)
Does it feel like something is cutting you?
Where is it? (Offer a diagram)
Does it feel like something is squeezing you?
Where is it? (Offer a diagram)
Does it feel like something is pulling on you?
Where is it? (Offer a diagram)
Do you have a name for the pain?
What is the name?
Does it ever make you think of another person?
Does it make you think of carrying a child?
What does this child do? (Offer several choices: whines, clings, sleeps, cries, feeds)
Does it make you think of an adult?
Who is this adult? (friend, spouse, stranger, parent, other relative)
Does it remind you of an animal?
What kind of animal?
What does the animal do?
Cause
I believe my pain is due to: (The effects of treatment, for example, medication, surgery, radiation, prosthetic device; My primary disease, meaning the disease currently being treated and evaluated; A medical condition unrelated to my primary disease, for example, arthritis. Please describe condition).
Interference
During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)?
To what extent do you feel that (physical) pain prevents you from doing what you need to do?
Circle the one number that describes how, during the past week, pain has interfered with your: A. General Activity (0 "Does not interfere" - 10 "Completely interferes").
Circle the one number that describes how, during the past week, pain has interfered with your: B. Mood (0 "Does not interfere" - 10 "Completely interferes). (23B) 2 Circle the one number that describes how, during the past week, pain has interfered with your: C. Walking Ability (0 "Does not interfere" 10 "Completely interferes").
Circle the one number that describes how, during the past week, pain has interfered with your: D. Normal Work (includes both work outside the home and housework) (0 "Does not interfere" - 10 "Completely interferes").
Circle the one number that describes how, during the past week, pain has interfered with your: E. Relations with other people (0 "Does not interfere" - 10 "Completely interferes").
Circle the one number that describes how, during the past week, pain has interfered with your: F. Sleep (0 "Does not interfere" - 10 "Completely interferes").
Circle the one number that describes how, during the past week, pain has interfered with your: G. Enjoyment of life (0 "Does not interfere" - 10 "Completely interferes"). What kinds of things make your pain worse (for example, walking, standing, lifting)? (Link to specific activity questions in "Health and Function" component.)
Strength or Coping
Questions about the degree to which the patient has avoided a situation in which potentially debilitating pain interferes with everyday life. What is the patient proud of or relieved by? (Link to "Self-treatment" and "Treatment Received" ("Non-Pharmacological") and "Patient Objectives" in this section, as well as "Health & Function" component, and "Spiritual and philosophical beliefs" section in "Well-Being" component.)
Treatment Received
Non-Pharmacological
What kinds of things [has your doctor suggested to] make your pain feel better (for example, heat, medicine, rest)?
Other methods [the doctor has suggested] I use to relieve my pain include: (Choose from Warm compresses; Cold compresses; Relaxation techniques; Distraction; Biofeedback; Hypnosis; Other (Please specify)).
Pharmacological (Link to "Medications" in "Health Care" component.)
What treatments or medications are you receiving for pain?
I take my pain medicine (how many times in a 24-hour period)
I prefer to take my pain medicine: (On a regular basis; Only when necessary; Do not take pain medicine)
Self-Treatment
Non-Pharmacological
What kinds of things [have you discovered on your own that] make your pain feel better (for example, heat, medicine, rest)?
Other methods I [have learned to use on my own] to relieve my pain include: (Choose from Warm compresses; Cold compresses; Relaxation techniques; Distraction; Biofeedback; Hypnosis; Other (Please specify)).
Pharmacological (Link to "Medications" in "Health Care" component.)
Medications not prescribed by my doctor that I take for pain are:
Satisfaction with Treatments (Link to "Treatment Received" and "Self-Treatment" in this section.)
In the last week, how much relief have pain treatments or medications provided? Please circle the one percentage that most shows how much relief you have received (0% "No Relief" 100% "Complete Relief")?
If you take pain medication, how many hours does it take before the pain returns?
Do you feel you need a stronger type of pain medication?
Are you having problems with side effects from your pain medication? If so, which side effects?
Do you feel you need to receive further information about your pain medication?
Dependency on Treatment or Help
I feel I have some form of pain now [from this illness] that requires medication each and every day (agree or disagree)
Do you feel you need to take more of the pain medication than your doctor has prescribed?
Are you concerned that you use too much pain
medication? If Yes, why?
Patient objectives
Questions linked to "Strength or Coping" and "Satisfaction with Treatments" sections above relating to the patient's goals for pain treatment; a minimum of x + y questions, where xis the number of "Strength" questions and y is the number of "Satisfaction" questions; minimum of seven questions.
Suggestions for improving pain
At least one follow-up question for each question in "Satisfaction" above; minimum of five questions.
Other Conditions (Reproduce primary diagnosis questions; minimum of 127 questions.)
History
Experience and Perception
Treatment Received
Self-Treatment
Satisfaction with Treatments
Dependency on Treatment or Help
Patient objectives
Suggestions for improving pain
Health Care
General
History (Link to "History" section of "Disease" component.)
Experience and Perception
Treatment Received
Medications
How dependent are you on [prescribed] medications?
How much do you need any medication to function in your daily life?
To what extent does your quality of life depend on use of medical substances or medical aids?
Self-Treatment
Indicate what YOU usually do when YOU experience a [stressful health] event:
I use alcohol or drugs to make myself feel better (agree or disagree).
I try to lose myself for a while by drinking alcohol or taking drugs (agree or disagree).
I drink alcohol or take drugs in order to think about it less (agree or disagree).
I use alcohol or drugs to help me get through it (agree or disagree).
Satisfaction with Treatment
Dependency on Treatment or Help
Patient Objectives
Suggestions for Improvement
Diagnosis of Interest
History
Experience and Perception
Treatment Received
Medications
Use
How dependent [does your present illness make] you on medications?
How much do you need any medication [specifically for this diagnosis] to function in your daily life?
To what extent does your quality of life depend on use of medical substances or medical aids [for this condition]?
Indicate what YOU usually do when YOU experience a [problem with this illness]:
I use alcohol or drugs to make myself feel better (agree or disagree).
I try to lose myself for a while by drinking alcohol or taking drugs (agree or disagree).
I drink alcohol or take drugs in order to think about it less (agree or disagree
I use alcohol or drugs to help me get through it (agree or disagree).
Side effects
(Provide list of potential side effects a, b, c)
How often during the [past] four weeks have you felt worried or upset as a result of side effects from your medication?
How often during the past four weeks have you felt side effects (a)
How much trouble have you had in the last four weeks as a result of side effect (b)?
How often during the past four weeks have you had side effect (c)?
How often during the last four weeks have you felt uncomfortable or embarrassed (i.e., self-conscious) as a result of side effects?
How often during the last four weeks have you been sad or tearful as a result of side effects?
Social services
How would you rate the quality of social services available to you? How satisfied are you with your access to health services?
How satisfied are you with the social care services [available to you]?
Outpatient
How much do you need any medical treatment to function in your daily life?
Did you see a doctor more than three times last year for any problem other than [your primary diagnosis]? (Link to "Other Conditions" under "Health Care" component.)
How much trouble or inconvenience (i.e., hassle) have you had during the last four weeks as a result of sitting in the waiting room at the clinic or hospital [for your primary diagnosis]?
How much trouble or inconvenience (i.e., hassle) have you had during the last four weeks as a result of waiting for treatment at the clinic or hospital [for your primary diagnosis]?
How much trouble or inconvenience (i.e., hassle) have you had during the last four weeks as a result of waiting to see a physician while visiting the clinic or hospital [for your primary diagnosis]?
Hospitalizations.
How much trouble or inconvenience (i.e. hassle) have you had during the last four weeks as a result of having to come to or stay at the clinic or hospital for medical care [for your primary diagnosis]?
Self-Treatment
Indicate what YOU usually do when YOU experience [have a stressful time with this disease]:
I use alcohol or drugs to make myself feel better (agree or disagree).
I try to lose myself for a while by drinking alcohol or taking drugs (agree or disagree).
I drink alcohol or take drugs in order to think about it less (agree or disagree).
I use alcohol or drugs to help me get through it (agree or disagree).
Satisfaction with Treatments
How easily are you able to get good medical care?
My doctor has helped to make my illness better (agree or disagree).
I have confidence in my doctor's management of my illness (agree or disagree).
I avoid troubling the doctor about my symptoms (agree or disagree).
I wish that my doctor talked more to me about my disease (agree or disagree).
My doctor tells me everything I want to know about my disease (agree or disagree). (Link to "Intellectual" section of "Well-Being" component (asks about satisfaction with access to information.))
I worry that my medication may have unwanted effects on my health (agree or disagree).
I find it easy to remember to take my medication (agree or disagree).
It embarrasses me if I have to take medications in public (agree or disagree).
Dependency on Treatments or Help
In the past month, how often have you had to take medication for your [illness]?
Did you take pain medications in the last 7 days? (Link to "Pharmacological" under "Pain" component.)
It is a good idea to increase or decrease medications without consulting the doctor (agree or disagree).
Social services
Patient Objectives
Suggestions for improvement
Other Conditions
History
Experience and Perception
Treatment Received
Medications
Use
Do you take medicine every day for any problem other than your [primary diagnosis)?
How dependent [do any other conditions make] you on medications?
How much do you need any medication [specifically for other conditions] to function in your daily life?
To what extent does your quality of life depend on use of medical substances or medical aids [for this condition]?
Indicate what YOU usually do when YOU experience a [problem with this other illness]:
I use alcohol or drugs to make myself feel better (agree or disagree).
I try to lose myself for a while by drinking alcohol or taking drugs (agree or disagree).
I drink alcohol or take drugs in order to think about it less (agree or disagree).
I use alcohol or drugs to help me get through it (agree or disagree).
Side effects
(Provide list of potential side effects a, b, c)
How often during the [past] four weeks have you felt worried or upset as a result of side effects from your medication [for a condition other than your primary diagnosis]?
How often during the past four weeks have you felt side effects (a)
How much trouble have you had in the last four weeks as a result of side effect (b)?
How often during the past four weeks have you had side effect (c)
How often during the last four weeks have you felt uncomfortable or embarrassed (i.e., self-conscious) as a result of side effects?
How often during the last four weeks have you been sad or tearful as a result of side effects?
Social services
How would you rate the quality of social services available to [assist you in dealing with this condition]?
How satisfied are you with your access to health services [for this condition]?
How satisfied are you with the social care services [available to you for this condition]?
Outpatient
How much do you need any medical treatment [for this other condition] to function in your daily life?
How much trouble or inconvenience (i.e., hassle) have you had during the last four weeks as a result of sitting in the waiting room at the clinic or hospital [for this other condition]?
How much trouble or inconvenience (i.e., hassle) have you had during the last four weeks as a result of waiting for treatment at the clinic or hospital [for this other condition]?
How much trouble or inconvenience (i.e., hassle) have you had during the last four weeks as a result of waiting to see a physician while visiting the clinic or hospital [for this other condition]?
Hospitalizations
How much trouble or inconvenience (i.e. hassle) have you had during the last four weeks as a result of having to come to or stay at the clinic or hospital for medical care [for this other condition]?
Self-Treatment
Indicate what YOU usually do when YOU experience [have a stressful time with this disease]:
I use alcohol or drugs to make myself feel better (agree or disagree).
I try to lose myself for a while by drinking alcohol or taking drugs (agree or disagree).
I drink alcohol or take drugs in order to think about it less (agree or disagree).
I use alcohol or drugs to help me get through it (agree or disagree).
Satisfaction with Treatments
How easily are you able to get good medical care [for this other condition]?
My doctor has helped to make my [other condition] better (agree or disagree).
I have confidence in my doctor's management of [this condition] (agree or disagree).
I avoid troubling the doctor about my symptoms [of this other condition] (agree or disagree).
I wish that my doctor talked more to me about [this other condition] (agree or disagree).
My doctor tells me everything I want to know about [this other condition] (agree or disagree).
(Link to "Intellectual" section of "Well-Being" component (asks about satisfaction with access to information.)
I worry that my medication [for this other condition] may have unwanted effects on my health (agree or disagree).
I find it easy to remember to take my medication [for this other condition] (agree or disagree).
It embarrasses me if I have to take medications [for this other condition] in public (agree or disagree).
Dependency on Treatments or Help
In the past month, how often have you had to take medication for your [this other condition]?
Did you take pain medications in the last 7 days [for pain related to this other condition]?
(Link to "Pharmacological" under "Pain" component.)
It is a good idea to increase or decrease medications [for this other condition] without consulting the doctor (agree or disagree).
Patient Objectives
Suggestions for improvement
Other than diagnosis of interest
Individual Response
General
History
Health Habits
Diet
Exercise
Non-medical substances (Link to "Self-treatment" sections
of "Pain" and "Health Care" components.)
Sleep
How well do you sleep?
Do you have any difficulties with sleeping?
How satisfied are you with your sleep?
How much do any sleep problems worry you?
How often during the last four weeks have youhad trouble getting a good night's sleep?
Health Effects
Physical
At any time [in your life] due to physical limitation, have you:
Cut down the amount of time you spent on work or other activities because of that condition?
Accomplished less than you would like because of that condition?
Been limited in the kind of work or other activities [you perform] because of that condition?
Had difficulty performing the work or other activities [you do) (for example, it took extra effort) because of that condition?
In the past 4 weeks due to physical limitation, have you:
Cut down the amount of time you spent on work or other activities?
In the past 4 weeks due to physical limitation, have you: Accomplished less than you would like?
Been limited in the kind of work or other activities [you perform]?
Had difficulty performing the work or other activities [you do] (for example, it took extra effort)?
How often during the last four weeks have you been able to continue activities outside the home? (includes employment, volunteer commitments, hobbies)
How much during the past four weeks have you been able to continue activities inside the home? (includes housework, laundry, meals)
Emotional
In the past 4 weeks due to emotional limitation, have you:
Cut down the amount of time you spent on work or other activities?
Accomplished less than you would like?
Not done work or other activities as carefully as usual?
During the past 4 weeks, to what extent has your physical health or emotional problems interfered with your normal social activities with family, friends, neighbors, or groups? During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)?
Experience and Perception
I can't enjoy a full life because of [health in general] (agree or disagree).
I do all the things I want to regardless of their effect on my [health] (agree or disagree).
Even when I feel well, I worry that [any health problems] might return at any time (agree or disagree).
Indicate what YOU usually do when YOU experience a [stressful health] event:
I concentrate my efforts on doing something about it (agree or disagree).
I take additional action to try to get rid of the problem (agree or disagree).
I take direct action to get around the problem (agree or disagree
I do what has to be done, one step at a time (agree or disagree).
I make a plan of action (agree or disagree).
I try to come up with a strategy about what to do (agree or disagree).
I think about how I might best handle the problem (agree or disagree).
I think hard about what steps to take (agree or disagree).
I put aside other activities in order to concentrate on this (agree or disagree).
I focus on dealing with this problem, and if necessary let other things slide a little (agree or disagree).
I try hard to prevent other things from interfering with my efforts at dealing with this (agree or disagree).
I keep myself from getting distracted by other thoughts or activities (agree or disagree).
I get upset and let my emotions out (agree or disagree).
I get upset, and am really aware of it (agree or disagree).,
I let my feelings out (agree or disagree).
I feel a lot of emotional distress and I find myself expressing those feelings a lot (agree or disagree).
I admit to myself that I can't deal with it, and quit trying (agree or disagree).
I just give up trying to reach my goal (agree or disagree).
I give up the attempt to get what I want (agree or disagree).
I reduce the amount of effort I'm putting into solving the problem (agree or disagree).
I say to myself, "This isn't real" (agree or disagree).
I refuse to believe that it has happened (agree or disagree).
I pretend that it hasn't really happened (agree or disagree).
I act as though it hasn't even happened (agree or disagree).
I force myself to wait for the right time to do something (agree or disagree
I make sure not to make matters worse by acting too soon (agree or disagree).
I restrain myself from doing anything too quickly (agree or disagree).
I hold off doing anything about it until the situation permits (agree or disagree).
Treatment Received (not applicable to "Individual Response" component)
Treatment Self-administered
Link to "Self-treatment" sections of "Pain" and "Health Care" components.
Indicate what YOU usually do when YOU experience a [stressful health] event:
I sleep more than usual (agree or disagree).
I turn to work or other substitute activities to take my mind off things (agree or disagree).
I daydream about things other than this (agree or disagree).
I go to movies or watch TV, to think about it less (agree or disagree).
Satisfaction with Treatments
(Link to "Satisfaction" section under "Health Care" component.)
Dependency on Treatment or Help
I know what things make [my health] worse (agree or disagree).
I know when [my health] is about to get worse (agree or disagree).
I can prevent [my health from] getting worse ( agree or disagree).
I don't do anything about [my health until it gets] bad ( agree or disagree).
I have confidence in my ability to cope when [I have health problems] (agree or disagree).
At the first sign that [my health is getting worse], I feel panicky and frightened (agree or disagree).
Patient Objectives Suggestions for Improvement
Diagnosis of Interest
History
At any time since your diagnosis due to physical limitation, have you:
Cut down the amount of time you spent on work or other activities because of that condition?
Accomplished less than you would like because of that condition?
Been limited in the kind of work or other activities [you perform] because of that condition
Had difficulty performing the work or other activities [you do] (for example, it took extra effort) because of that condition?
Experience and Perception
I can't enjoy a full life because of my illness (agree or disagree).
I do all the things I want to regardless of their effect on my illness (agree or disagree).
Even when I feel well, I worry that the symptoms might return at any time (agree or disagree).
In the past 4 weeks due to [symptoms of this disease], have you:
Cut down the amount of time you spent on work or other activities?
Accomplished less than you would like?
Been limited in the kind of work or other activities [you perform]?
Had difficulty performing the work or other activities [you do] (for example, it took extra effort)?
I would like you to think of the activities that you have done since your diagnosis that have become more difficult or have made your symptoms worse. These should be activities which you do frequently and which are important in your day-to-day life. (Link the following to specific function questions for the appropriate limb or body region in "Health and Function" component.)
Does being angry or upset cause problems or make your symptoms worse?
Does having a bath or shower cause problems or make your symptoms worse?
Does bending at the waist cause problems or make your symptoms worse?
Does carrying, such as carrying groceries cause problems or make your symptoms worse?
Does dressing cause problems or make your symptoms worse?
Does eating cause problems or make your symptoms worse?
Does going for a walk cause problems or make your symptoms worse?
Does doing your housework cause problems or make your symptoms worse?
Does hurrying cause problems or make your symptoms worse?
Does lying fiat cause problems or make your symptoms worse?
Does making a bet cause problems or make your symptoms worse?
Does mopping or scrubbing the floor cause problems or make your symptoms worse?
Does moving furniture cause problems or make your symptoms worse?
Does playing with children or grandchildren cause problems or make your symptoms worse?
Does playing sports cause problems or make your symptoms worse?
Does reaching over your head cause problems or make your symptoms worse?
Does running, such as for a bus cause problems or make your symptoms worse?
Does shopping cause problems or make your symptoms worse?
Does vacuuming cause problems or make your symptoms worse?
Does walking around your own home cause problems or make your symptoms worse?
Does walking uphill cause problems or make your symptoms worse?
Does walking upstairs cause problems or make your symptoms worse?
Does walking with others on level ground cause problems or make your symptoms worse?
Does preparing meals cause problems or make your symptoms worse?
Do your symptoms cause problems or become worse when you are trying to sleep?
Are there any other activities that have caused you problems since your diagnosis?
Of the activities that have caused you problems, which is the most important to you in your day-to-day life? I will read through the items, and when I am finished, I would like you to tell me which is the most important.
Of the remaining items, which is the most important to you in your day-to day life?
Of the remaining items, which is the most important to you in your day-to day life?
Of the remaining items, which is the most important to you in your day-to day life?
Of the remaining items, which is the most important to you in your day-to day life?
Treatment Received (Not applicable to "Individual Response" component.)
Treatment Self-administered
Link to "Self-treatment" sections of "Pain" and "Health Care" components.
Indicate what YOU usually do when YOU experience a [stressful time with your primary diagnosis]:
I sleep more than usual (agree or disagree).
I turn to work or other substitute activities to take my mind off things (agree or disagree).
I daydream about things other than this (agree or disagree
I go to movies or watch TV, to think about it less (agree or disagree).
Satisfaction with Treatments
(Link to "Satisfaction" section of relevant divisions of "Pain" and "Health Care" components.)
Dependency on Treatment or Help
I know what things make my symptoms [of this disease] worse
(agree or disagree).
I know when the symptoms are about to get worse (agree or
disagree).
I can prevent the symptoms from flaring up or getting worse
(agree or disagree).
I don't do anything about my symptoms until they get bad
(agree or disagree).
I have confidence in my ability to cope when the symptoms
flare up (agree or disagree).
At the first sign that the symptoms are flaring up, I feel panicky
and frightened (agree or disagree).
Suggestions for Improvement Patient Objectives
Other conditions (Reflects questions from "Diagnosis of Interest", minimum 57 questions.)
Health and Function
General Health
History
In general, [has your health been] excellent, good, fair, or poor?
In general, would you say your health [has been]:
(How true or false) My health [has been] excellent.
Experience and Perception
In general, would you say that your health now is excellent, good, fair, or poor?
In general, would you say your health is:
(How true or false) My health is excellent
Compared to one year ago, how would you rate your health in general now?
How much of your problem with your health now is due to your arthritis?
In general, do you expect that your health ten years from now will be excellent, good, fair, or poor?
(How true or false) I expect my health to get worse.
How big a problem do you expect your [health] to be ten years from now?
Treatment or Assistance Received
Self-treatment
Satisfaction
How satisfied are you with your health?
How satisfied are you with your health now?
Considering all the ways that your [health] affects you, how well are you doing compared to other people your age?
(How true or false) I am as healthy as anybody I know.
(How true or false) I seem to get sick a little easier than other people
Dependency on treatment or help
Patient objectives
Suggestions for improvement
Pick up to three areas in which you would like to see improvement (choice: Mobility Level, Walking & Bending, Hand & Finger Function, Arm Function, Self-Care, Household Tasks, Social Activity, Support from Family, Arthritis Pain,
Work, Level of Tension, Mood)
General Mobility
Household
History
Experience and Perception
In the past month: How often were you in a bed or chair for most or all of the day?
How well are you able to get around?
In the past month: How much of your problem with mobility level was due to [your primary diagnosis]?
Treatment or Assistance Received
Self-Treatment
Satisfaction
How satisfied are you with your ability to move around?
In the past month: How satisfied have you been with your mobility level?
How much do any difficulties in mobility bother you?
To what extent do any difficulties in movement affect your way of life?
Dependency on Treatment or Help
Patient Objectives
Suggestions for Improvement
Household
Transportation
History
Experience and Perception
In the past month: How often were you out of the house for at least part of the day?
In the past month: How often were you able to do errands in the neighborhood?
In the past month: How often were you physically able to drive a car or use public transportation?
Treatment or Assistance Received
Self-Treatment
Satisfaction with Treatments
To what extent do you have adequate means of transport?
To what extent do you have problems with transport?
How satisfied are you with your transport?
How much do difficulties with transport restrict your life?
Dependency on Treatment or Help
In the past month: How often did someone have to assist you to get around outside your home?
Patient Objectives
Suggestions for Improvement
Function related to diagnosis in question
Body Regions
Arm and Upper Body
History
Have you had problems with arm function before?
In the past month: How much of your problem with arm function was due to [your primary diagnosis]?
Experience and Perception
Does your health now limit you in: Lifting or carrying groceries?
In the past month: Could you easily wipe your mouth with a napkin?
In the past month: Could you easily put on a pullover sweater?
In the past month: Could you easily scratch your low back with your hand?
In the past month: Could you easily reach shelves that were above your head?
Treatment or Assistance Received
Self-treatment
Satisfaction
In the past month: How satisfied have you been with your arm function?
Dependency on treatment or help
Patient objectives
Suggestions for Improvement
Hand
History
Experience and Perception
In the past month: How much of your problem with hand and finger function was due to [your principal diagnosis]?
Does your health now limit you in: Lifting or carrying groceries?
In the past month: Could you easily write with a pen or pencil?
In the past month: Could you easily button a shirt or blouse?
In the past month: Could you easily turn a key in lock?
In the past month: Could you easily tie a knot or bow?
In the past month: Could you easily open a new jar of food?
Treatment or Assistance Received
Self-treatment
Satisfaction
In the past month: How satisfied have you been with your hand and finger function?
Dependency on treatment or help
Patient objectives
Suggestions for improvement
Leg Function and Walking
History
Experience and Perception
In the past month: How much of your problem with walking and bending was due to [this diagnosis]?
In the past month: Were you unable to walk unless assisted by another person or by a cane, crutches, or a walker
Does your health now limit you in:
Climbing several flights of stairs?
Climbing one flight of stairs?
Bending, kneeling, or stooping?
Walking more than a mile?
Walking several blocks?
Walking one block?
In the past month: Did you have trouble either walking several blocks or climbing a few flights of stairs?
In the past month: Did you have trouble either walking one block or climbing one flight of stairs?
Treatment or Assistance Received
Self-treatment
Satisfaction
In the past month: How satisfied have you been with your walking and bending?
Dependency on treatment or help
Patient objectives
Suggestions for improvement
Back Function and Walking
History
Experience and Perception
Does your health now limit you in: Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports?
In the past month: Did you have trouble doing vigorous activities such as running, lifting heavy objects, or participating in strenuous sports?
Does your health now limit you in: Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf?
In the past month: Did you have trouble bending, lifting, or stooping?
Does your health now limit you in: Lifting or carrying groceries?
Treatment or Assistance Received
Self-treatment
Satisfaction
In the past month: How satisfied have you been with your walking and bending?
Dependency on treatment or help
Patient objectives
Suggestions for improvement
Personal and Self-Care Activities
History
Experience and Perception
To what extent are you able to carry out your daily activities?
To what extent do you have difficulty performing your routine activities?
Does your health now limit you in: Bathing or Dressing yourself?
In the past month: Did you need help to take a bath or shower?
In the past month: Did you need help to get dressed?
In the past month: Did you need help to use the toilet?
In the past month: Did you need help to get in or out of bed?
In the past month: How much of your problem with self-care was due to arthritis?
Treatment or Assistance Received
Self-treatment
Satisfaction
How satisfied are you with your ability to perform your daily living activities?
In the past month: How satisfied have you been with your self-care?
How much are you bothered by any limitations in performing your everyday living activities?
Dependency on treatment or help
Patient objectives
Suggestions for improvement Work
History
What has been your main form of work?
Are you able to work?
How would you rate your ability to work?
Experience and Perception
Do you feel able to carry out your duties?
In the past month: How much of your problem with household tasks was due to [the diagnosis in question]?
In the past month: How much of your problem in work was due to [the primary diagnosis]?
How often were you unable to do any paid work, housework, or schoolwork?
On the days that you did work, how often did you have to work a shorter day?
On the days that you did work, how often were you unable to do your work as carefully and accurately as you would like?
On the days that you did work, how often did you have to change the way your paid work, housework, or schoolwork is usually done?
Treatment or Assistance Received
Self-treatment
Satisfaction
In the past month: How satisfied have you been with your household tasks?
In the past month: How satisfied have you been with work?
How satisfied are you with your capacity for work?
Dependency on treatment or help
In the past month: If you had the necessary transportation, could you go shopping for groceries without help?
In the past month: If you had kitchen facilities, could you prepare your own meals without help?
In the past month: If you had household tools and appliances, could you do your own housework without help?
In the past month: If you had laundry facilities, could you do your own laundry without help?
Patient objectives
Suggestions for improvement
Social Activity
(Link to "Social Environment" component.)
Recreation
History
Experience and Perception
To what extent do you have the opportunity for leisure activities?
How much are you able to relax and enjoy yourself?
Treatment or Assistance Received
Self-treatment
Satisfaction
How much do you enjoy your free time?
How satisfied are you with the way you spend your spare time?
Dependency on treatment or help
Patient objectives
Suggestions for improvement
Function related to other conditions
(Reproduce primary diagnosis questions; minimum of 62 questions.)
Social Environment
General
Material support
(Link to "Social Services" section of "Health Care" component, and to "Material Security" section of "Prosperity" component.)
Social Networks Intimate Support
Diagnosis in Question
Material support
(Link to "Social Services" section of "Health Care" component, and to "Material Security" section of "Prosperity" component.)
Social Networks
History
Experience and Perception
I feel different from other people because of my illness (agree or disagree).
I avoid letting other people know I have this illness (agree or disagree).
The people who are closest to me seem overly protective of me because of my illness (agree or disagree).
How much of the time during the last four weeks would you say that your family has been worried about you, and about your health [because of this diagnosis]?
In the past month: How often did you go to a meeting of a church, club, team, or other group?
How much help and support have you received from people outside your family during the last four weeks?
Treatment or Assistance Received
Indicate what YOU usually do when YOU experience a [stressful health] event:
I get sympathy and understanding from someone (agree or disagree).
Self-Treatment
Indicate what YOU usually do when YOU experience a [stressful health] event:
I discuss my feelings with someone (agree or disagree).
I try to get emotional support from friends or relatives (agree or disagree).
I talk to someone about how I feel (agree or disagree).
I try to get advice from someone about what to do (agree or disagree).
I talk to someone to find out more about the situation (agree or disagree).
I talk to someone who could do something concrete about the problem (agree or disagree).
I ask people who have had similar experiences what they did (agree or disagree).
Satisfaction
I am worried that my illness may interfere with the lives of the people closest to me (agree or disagree).
In the past month: How satisfied have you been with your social activities?
How alone do you feel in your life?
Do you get the kind of support from others that you need?
To what extent can you count on your friends when you need them?
How satisfied are you with the support you get from your friends
In the past month: How much of your problem with social activities was due to [your primary diagnosis]?
Dependency on Treatment or Help
Patient Objectives
Suggestions for Improvement
Intimate Support
History
What is your marital status?
Experience and Perception
In the past month:
How often did you get together with friends or relatives?
How often did you have friends or relatives over to your home?
In the past month: How often did you visit friends or relatives at their homes?
How often were you on the telephone with close friends or relatives?
Treatment or Assistance Received
Self-Treatment
Satisfaction
In the past month: How satisfied have you been with your support from family and friends?
How satisfied are you with your personal relationships?
Do you feel happy about your relationship with your family members?
In the past month:
Did you feel that your family or friends would be around if you needed assistance?
Did you feel that your family or friends were sensitive to your personal needs?
Did you feel that your family or friends were interested in helping you solve problems?
Did you feel that your family or friends understood the effects of your [illness]?
How satisfied are you with the support you get from your family?
In the past month: How much of your problem with support from family and friends was due to [your primary diagnosis]? (
How would you rate your sex life?
How well is your sexual needs fulfilled?
Are you bothered by any difficulties in your sex life?
How satisfied are you with your sex life?
Dependency on Treatment or Help
Patient Objectives
Suggestions for Improvement
Other Conditions
(Reproduce primary diagnosis questions; minimum of 30 questions.)
Physical Environment*
Community
History
Experience and Perception
How healthy is your physical environment?
How concerned are you with noise in the area you live in?
How safe do you feel in your daily life?
Do you feel you are living in a safe and secure environment?
Treatment or Assistance Received
Self-Treatment
Satisfaction
How satisfied are you with your physical environment (e.g. pollution, climate, noise, attractiveness)?
How satisfied are you with the climate of the place where you live?
How much do you worry about your safety and security?
How satisfied are you with physical safety and security?
Dependency on Treatment or Help
Patient Objectives
Suggestions for Improvement
Home
History
Experience and Perception
How comfortable is the place where you live?
To what extent does the quality of your home meet your needs
Treatment or Assistance Received
Self-Treatment
Satisfaction
How satisfied are you with the conditions of your living place?
How much do you like it where you live?
Dependency on Treatment or Help
Patient Objectives
Suggestions for Improvement
Prosperity
Material security
History
What is your approximate family income including wages, disability payment, retirement income, and welfare?
What is the highest level of education you received?
What is your current occupation?
What is your spouse's occupation?
What is your current job status (retired, etc.)?
Experience and Perception
How available to you is the information you need in your day-to-day life?
(Link to "Satisfaction" section of "Health Care" component; questions dealing with appropriateness of information from physician.)
To what extent do you have opportunities for acquiring information that you feel you need?
(Link to "Satisfaction" section of "Health Care" component; questions dealing with appropriateness of information from physician.)
Have you enough money to meet your needs?
Do you have financial difficulties?
Treatment or Assistance Received Satisfaction
How satisfied are you with your financial situation?
How much do you worry about money?
How satisfied are you with your ability to provide for or support?
How satisfied are you with your opportunities for acquiring skills?
How satisfied are you with your opportunities to learn new information?
(Link to "Satisfaction" section of "Health Care" component; questions dealing with appropriateness of information from physician.)
Self-Treatment (Not applicable)
Dependency on Treatment or Help
Patient Objectives
Suggestions for Improvement
Social security and support
(Link to "Social Networks" under "Social Environment")
History
Experience and Perception
Treatment or Assistance Received
Self-Treatment
Satisfaction
Dependency on Treatment or Help
Patient Objectives
Suggestions for Improvement
Well-Being
General
Physical
Appearance
History
Experience1and Perception
Treatment or Assistance Received
Self-Treatment
Satisfaction
Are you able to accept your bodily appearance?
Do you feel inhibited by your looks?
Is there any part of your appearance that makes you feel uncomfortable?
How satisfied are you with the way your body looks?
How often during the past four weeks have you been troubled or upset as a result of feeling unattractive (i.e., like you don't look good)?
Dependency on Treatment or Help
Patient Objectives
Suggestions for Improvement
Health
History
Experience and Perception
How would you rate your quality of life?
How satisfied are you with your quality of life?
In general, how satisfied are you with your life?
How often during the past four weeks have you felt optimistic or positive regarding the future?
How much of the time during the last four weeks have you felt the future looks hopeful and promising?
How often during the last four weeks have you felt good about yourself?
How often do you have negative feelings, such as blue mood, despair, anxiety, depression?
How often during the last four weeks have you felt low in energy?
(Link to "Emotional" section of "Well-Being")
Do you have enough energy for everyday life?
(Link to "Emotional" section of "Well-Being")
How easily do you get tired?
(Link to "Emotional" section of "Well-Being")
During the past 4 weeks: Did you have a lot of energy?
(Link to "Emotional" section of "Well-Being")
During the past 4 weeks: Did you feel full of pep?
(Link to "Emotional" section of "Well-Being")
During the past 4 weeks: Did you feel worn out?
(Link to "Emotional" section of "Well-Being")
During the past 4 weeks: Did you feel tired?
(Link to "Emotional" section of "Well-Being")
How much of the time during the last four weeks have you felt drowsy during the day?
(Link to "Emotional" section of "Well-Being")
Treatment or Assistance Received Self-Treatment
Indicate what YOU usually do when YOU experience a [stressful health] event:
I laugh about the situation (agree or disagree
I make jokes about it (agree or disagree).
I kid around about it (agree or disagree).
I make fun of the situation (agree or disagree).
Satisfaction
Dependency on Treatment or Help
Patient Objectives
Suggestions for Improvement
Emotional
History
Have you had 2 years or more when you felt depressed or sad most days, even if you felt okay sometimes?
In general, how often during the last four weeks have you felt frustrated or irritable?
In general, how often during the last four weeks have you felt tearful or down in the dumps?
In general, how much of the time during the last 2 weeks have you felt frustrated or impatient?'3 How happy, satisfied, or pleased have you been with your personal life during the last 2 weeks?
Experience and Perception
General
In general, how much of the time did you feel upset, worried, or depressed during the last 2 weeks?
How much do you enjoy life?
Do you generally feel content?
In the past month: How often have you enjoyed the things you do?
How positive do you feel about the future
How much do you experience positive feelings in your life?
How much do you value yourself?
How much confidence do you have in yourself?
Fatigue
How tired have you felt over the last 2 weeks?
How much energy have you had in the last 2 weeks?
How often during the last four weeks have you felt tired or fatigued while hurrying?
How often during the last 2 weeks have you felt low in energy?
How often during the last 2 weeks have you felt worn out or sluggish?
Anxiety
How worried do you feel?
In general, how often during the last four weeks have you felt worried or tense?
During the past 4 weeks: Have you been a very nervous person?
During the past 4 weeks: Have you felt calm and peaceful
In the past month: How often have you felt calm and peaceful?
In the past month: How often were you able to relax without difficulty?
In the past month: How often have nervousness or your nerves bothered you?
In the past month: How often have you felt tense or high-strung?
In the past month: How often have you felt relaxed and free of tension?
In general, how often during the last 2 weeks have you felt restless, tense, or uptight?
Depression
Have you felt depressed or sad much of the time in the past year?
In the past year, have you had 2 weeks or more during which you felt sad, blue, or depressed; or when you lost all interest in things that you usually cared about or enjoyed?
During the past 4 weeks: Have you felt so down in the dumps that nothing could cheer you up?
During the past 4 weeks: Have you felt downhearted and blue?
In the past month: How often have you been in low or very low spirits?
In the past month: How often did you feel that others would be better off if you were dead?
How often during the last 2 weeks have you felt inadequate, worthless, or as if you were a burden on others?
In general, how often during the last 2 weeks have you felt discouraged or down in the dumps?
Treatment or Assistance Received
Self-Treatment
Satisfaction
How satisfied are you with the energy that you have?
How bothered are you by fatigue?
How often during the last four weeks have you had problems with fatigue or tiredness which interfered with your housework?
(Link to "Work" section of "Health and Function" component.)
In the past month: How satisfied have you been with your level of tension?
How much of the time during the last four weeks have you had problems with [fatigue] or tiredness which limited your usual social activities?
(Link to "Social Networks" section of "Social Environment" component.)
How much do feelings of sadness or depression interfere with your everyday functioning?
How much do any feelings of depression bother you?
During the past 4 weeks: Have you been a happy person?
In the past month: How satisfied have you been with your mood?
How satisfied are you with yourself?
How satisfied are you with your abilities?
In the past month: How often did you feel that nothing turned out the way you wanted it to?
Dependency on Treatment or Help
Patient Objectives
Suggestions for Improvement Intellectual
History
Experience and Perception
How would you rate your memory?
How well are you able to concentrate?
Treatment or Assistance Received
Self-Treatment
Satisfaction
How satisfied are you with your ability to learn new information?
(Link to "Satisfaction" section of "Health Care" components)
How satisfied are you with your ability to make decisions?
Dependency on Treatment or Help
Patient Objectives
Suggestions for Improvement Spiritual and Philosophical
History
Do your personal beliefs give meaning to your life?
To what extent do you feel your life to be meaningful?
Experience and Perception
Indicate what YOU usually do when YOU experience a stressful event:
I put my trust in God (agree or disagree).
I seek God's help (agree or disagree).
I try to find comfort in my religion (agree or disagree
I pray more than usual (agree or disagree)
I try to grow as a person as a result of the experience (agree or disagree).
I try to see it in a different light, to make it seem more positive (agree or disagree).
I look for something good in what is happening (agree or disagree).
I learn something from the experience (agree or disagree).
I get used to the idea that it happened (agree or disagree).
I accept that this has happened and that it can't be changed (agree or disagree).
I accept the reality of the fact that it happened (agree or disagree
I learn to live with it (agree or disagree).
Treatment or Assistance Received
Self-Treatment
Satisfaction
To what extent do your personal beliefs give you the strength to face difficulties?
To what extent do your personal beliefs help you to understand difficulties in life?
Dependency on Treatment or Help
Patient Objectives
Suggestions for Improvement
Diagnosis of Interest
(In addition to the questions below, a disease-specific follow-up of almost all the "General" questions could be asked, filling the same categories as filled above; this adds a minimum of 93 questions.)
Physical
Appearance
History
Experience and Perception
My illness has made me physically less attractive (agree or disagree).
Treatment or Assistance Received
Self-Treatment
Satisfaction
Dependency on Treatment or Help
Patient Objectives
Suggestions for Improvement
Health
History
Experience and Perception
Treatment or Assistance Received
Self-Treatment
Satisfaction
Dependency on Treatment or Help
Patient Objectives
Suggestions for Improvement
Emotional
History
Experience and Perception
General
Having this diagnosis often makes me feel angry (agree or disagree).
I feel somehow to blame for being sick (agree or disagree).
I became sick because of an emotional upset (agree or disagree).
Fatigue
Anxiety
In the past month: How much of your problem with tension was due to [your primary diagnosis]?
How often during the last 2 weeks did you feel upset or scared when you had difficulty with your symptoms?
How often during the past 2 weeks did you have a feeling of fear or panic when you had symptoms from your condition?
Depression
Having this diagnosis often makes me feel depressed (agree or disagree).
Treatment or Assistance Received
Self-Treatment
Satisfaction
In the last 2, weeks, how much of the time did you feel very confident and sure that you could deal with your illness?
How often during the last 2 weeks did you feel you had complete control of your symptoms?
Dependency on Treatment or Help
Patient Objectives
Suggestions f6ur Improvement
Intellectual
Spiritual and Philosophical
History
Experience and Perception
Treatment or Assistance Received
Self-Treatment
Satisfaction
Dependency on Treatment or Help
Patient Objectives
Suggestions for Improvement
Other Conditions (Reproduce questions for "Diagnosis of Interest"; minimum 103 questions.)