Quality of Life Questionnaire

Trial Number………………..…………..

Date……………………………..………..

Patient initials……………………………

6 Month

AML17 Trial

QUALITY OF LIFE STUDY

This booklet contains a set of questions which have been developed to study any possible
long-term effects of your illness and treatment. The aim of the study is to improve our
knowledge about any physical and psychosocial side effects of leukaemia therapy in order
to identify areas where more help could be offered to patients. We would be grateful if you
could help us in our research by completing this questionnaire. The information you
provide will be kept strictly confidential and used only for medical research.

Please note that your doctor will not see the answers you give and, if you have specific
symptoms or problems as indicated here, you may need to discuss these with your doctor
in person.

If you find any of the questions are irrelevant or difficult please make a note of this on the
last page.

UK (English) © 1990 EuroQol Group EQ-5D™ is a trade mark of the EuroQol Group
 EORTC QLQ-C30 Version 3

Please answer all the questions yourself by ticking the box that best applies to you.

There are no “right” or “wrong” answers.

Please enter the date on which you completed this questionnaire: ………./………./……….

Section 1: Current Health Condition

Not A Quite Very

at all little a bit much

1. Do you have any trouble doing strenuous activities,

like carrying a heavy shopping bag or suitcase?

2. Do you have any trouble taking a long walk

3. Do you have any trouble taking a short walk

outside of the house?

4. Do you have to stay in a bed or a chair most of the

day?

5. Do you need help with eating, dressing, washing

yourself or using the toilet?

For the next two questions please circle the number between 1 and 7 that best applies to you.

6. How would you rate your overall health during the past week?

1 2 3 4 5 6 7
Very Poor Excellent

7. How would you rate your overall quality of life during the past week?

1 2 3 4 5 6 7
Very Poor Excellent

Not A Quite Very

1.1 During the Past Week at all little a bit much
8. Were you limited in doing either your work or other
daily activities?
9. Were you limited in pursuing your hobbies or other
leisure time activities?

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 10. Were you short of breath?

11. Have you had pain?

12. Did you need to rest?

13. Have you had trouble sleeping?

14. Have you felt weak?

15. Have you lacked an appetite?

16. Have you felt nauseated?

17. Have you vomited?

18. Have you been constipated?

19. Have you had diarrhoea?

20. Were you tired?

21. Did pain interfere with your daily activities?

22. Have you had difficulty in concentrating on things,

like reading a newspaper or watching television?
23. Did you feel tense?

24. Did you worry?

25. Did you feel irritable?

26. Did you feel depressed?

27. Have you had difficulty remembering things?

28. Has your physical condition or medical treatment

interfered with your family life?
29. Has your physical condition or medical treatment
interfered with your social activities?
30. Has your physical condition or medical treatment
caused you financial difficulties?

Patients sometimes report that they have some of the following symptoms. This time we would like
to know whether you have experienced any of these symptoms during the past month.

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During the PAST MONTH, have you had problems with:

Not at A Quite Very

all little a bit much
31. Chills

32. Fever

33. Infection

34. Weight loss

35. Weight gain

36. Change in your sense of taste

37. Change in your sense of smell

38. Pain in abdomen (belly)

39. Sores in mouth

40. Mouth dryness

41. Eye dryness

42. Difficulty in swallowing

43. Dental problems

44. Cough

45. Skin itching

46. Skin dryness

47. Hair loss

48. Abnormal hair growth

49. Changes in your appearance

50. Stiff joints

51. Combing your hair

52. Shaving or making up

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 Not at A Quite a Very
all little bit much

53. Dizziness

54. Feeling cold

55. Flushes

56. Headaches

57. Blurred vision

58. Hearing loss

59. Pain during sexual intercourse

60. Anal pain

61. Painful urination

62. Blood in urine

Please continue to Section 2: Emotions, on the next page

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Section 2: Emotions
This section of the questionnaire is designed to help us know how you feel. Please read each item
and place a tick in the box opposite the reply which comes closest to how you have been feeling in
the past week. Don’t take too long over our replies: your immediate reaction to each item will
propably be more accurate than a long thought-out response.
Tick only one box
for each question
63 I feel tense or ‘wound up’:
Most of the time
A lot of the time
Time to time, occasionally
Not at all
64 I still enjoy the things I used to enjoy:
Definitely as much
Not quite so much
Only a little
Hardly at all
65 I get a sort of frightened feeling as if something awful is about to happen:
Very definitely and quite badly
Yes, but not too badly
A little, but it doesn’t worry me
Not at all
66 I can laugh and see the funny side of things:
As much as I always could
Not quite so much now
Definitely not so much now
Not at all
67 Worrying thoughts go through my mind:
A great deal of the time
A lot of the time
From time to time but not too often
Only occasionally
68 I feel cheerful:
Not at all
Not often
Sometimes
Most of the time

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69 I can sit at ease and feel relaxed:
Definitely
Usually
Not often
Not at all
70 I feel as if I am slowed down:
Nearly all the time
Very often
Sometimes
Not at all
71 I get a sort of frightened feeling like ‘butterflies’
in the stomach:
Not at all
Occasionally
Quite often
Very often
72 I have lost interest in my appearance:
Definitely
I don’t take so much care as I should
I may not take quite as much care
I take just as much care as ever
73 I feel restless as if I have to be on the move:
Very much indeed
Quite a lot
Not very much
Not at all
74 I look forward with enjoyment to things:
As much as ever I did
Rather less than I used to
Definitely less than I used to
Hardly at all
75 I get sudden feelings of panic:
Very often indeed
Quite often
Not very often
Not at all
76 I can enjoy a good book or radio or TV
programme:
Often
Sometimes
Not often
Seldom

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By placing a tick in one box in each group below, please indicate which statements
best describe your own health state today.

Mobility
I have no problems in walking about q
I have some problems in walking about q
I am confined to bed q

Self-Care
I have no problems with self-care q
I have some problems washing or dressing myself q
I am unable to wash or dress myself q

Usual Activities (e.g. work, study, housework, family or

leisure activities)
I have no problems with performing my usual activities q
I have some problems with performing my usual activities q
I am unable to perform my usual activities q

Pain/Discomfort
I have no pain or discomfort q
I have moderate pain or discomfort q
I have extreme pain or discomfort q

Anxiety/Depression
I am not anxious or depressed q
I am moderately anxious or depressed q
I am extremely anxious or depressed q

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 Best
imaginable
health state
To help people say how good or bad a health state is, we 100
have drawn a scale (rather like a thermometer) on which
the best state you can imagine is marked 100 and the
worst state you can imagine is marked 0.
9 0
We would like you to indicate on this scale how good
or bad your own health is today, in your opinion.
Please do this by drawing a line from the box below to
whichever point on the scale indicates how good or bad 8 0
your health state is today.

7 0

6 0

Your own
health state 5 0
today

4 0

3 0

2 0

1 0

0
Worst
imaginable
health state

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Personal Details

77a Sex Male Female

77b Date of Birth ………….….……….…….……….…….

77c Marital Status

Married/living together
Widowed
Divorced/separated
Single

78 Present Employment Status

Full-time
Part-time
On sick-leave
Unemployed
Retired
Other

If ‘Other’ please specify…………………………

If now unemployed, was this as a direct result of your illness:

Yes No

Please continue to Patient’s Evaluation of the Questionnaire on the next page.

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Patient’s evaluation of questionnaire

79 Did anyone help you to complete the questionnaire?

No Yes

If YES, who helped you?…………………………………………………………….

80 Were there any questions that you found confusing or difficult to answer?

No Yes

If YES, please list the question number(s)…………………………………………

81 Were there any questions that you found upsetting?

No Yes

If YES, please list the question number(s)…………………………………………

Please use the space below if you have other comments:

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Thank you for your time and co-operation in answering these

questions.

Please return the questionnaire to the AML Trials Office in the reply paid
envelope provided.

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