QDRL - Disability Study

Attachment 1 – Instrument to be cognitively tested.

OMB #0920-0222; Expiration Date: 02/28/10

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QUALITY OF LIFE

1. In general, would you say your quality of life is:…..

1. Excellent

2.Very good

3.Good

4.Fair

5. Poor

2. In general, how would you rate your physical health:….

1. Excellent

2. Very good

3. Good

4. Fair

5. Poor

3. In general, how would you rate your mental health, including your mood and your ability to think?

1. Excellent

2. Very good

3. Good

4. Fair

5. Poor

4. In general, how would you rate your satisfaction with your social activities and relationships?

1. Excellent

2. Very good

3. Good

4. Fair

5. Poor

COMMUNICATION

5. Using your usual language, do you have difficulty communicating, for example understanding or being understood?

1. No difficulty

2. Some difficulty

3. A lot of difficulty

4. Cannot do at all / Unable to do

6. Do people have difficulty understanding you when you speak?

1. No difficulty

2. Some difficulty

3. A lot of difficulty

4. Cannot do at all / Unable to do

UPPER BODY

7. Do you have difficulty raising a 2 liter bottle of water or soda from waist to eye level?

1. No difficulty

2. Some difficulty

3. A lot of difficulty

4. Cannot do at all / Unable to do

8. Do you have difficulty using your hands and fingers, such as picking up small objects, for example, a button or pencil, or opening or closing containers or bottles?

1. No difficulty

2. Some difficulty

3. A lot of difficulty

4. Cannot do at all / Unable to do

COGNITION (REMEMBERING)

9. Do you have difficulty remembering or concentrating?

1. No difficulty (Go to Q 13)

2. Some difficulty

3. A lot of difficulty

4. Cannot do at all / Unable to do

10. Do you have difficulty remembering, concentrating, or both?

1. Difficulty remembering only (Ask 11a and 11b)

2. Difficulty concentrating only (Ask 12)

3. Difficulty with both remembering and concentrating (Ask 11a, 11b and 12)

11a. How often do you have difficulty remembering?

1. Sometimes

2. Often

3. All of the time

11b. Do you have difficulty remembering a few things, a lot of things, or almost everything?

1. A few things

2. A lot of things

3. Almost everything

12. How much difficulty do you have concentrating for ten minutes?

1. A little

2. A lot

3. Somewhere in between a little and a lot

LEARNING

13. Do you have difficulty understanding and following instructions for example, to use a new cell phone or to get to a new place?

1. No difficulty

2. Some difficulty

3. A lot of difficulty

4. Cannot do at all / Unable to do

AFFECT (ANXIETY AND DEPRESSION)

14. How often do you feel worried, nervous or anxious?

1. Daily

2. Weekly

3. Monthly

4. A few times a year

5. Never (Go to Q 15)

14a . Do you take medication for these feelings?

1. Yes

2. No

14b. Thinking about the last time you felt worried, nervous or anxious, how would you

describe the level of these feelings?

1. A little (Go to Q15)

2. A lot (Go to Q15)

3. Somewhere in between a little and a lot

14c.Would you say this was closer to a little, closer to a lot, or exactly in the middle?

1. Closer to a little

2. Closer to a lot

3. Exactly in the middle

15. How often do you feel depressed?

1. Daily

2. Weekly

3. Monthly

4. A few times a year

5. Never

15a. Do you take medication for depression?

1. Yes

2. No

15b. Thinking about the last time you felt depressed, how depressed did you feel?

1. A little (Go to Q16)

2. A lot (Go to Q16)

3. Somewhere in between a little and a lot

15c. Would you say this was closer to a little, closer to a lot, or exactly in the middle?

1. Closer to a little

2. Closer to a lot

3. Exactly in the middle

PAIN

16. Do you have frequent pain?

1. Yes

2. No (Go to Q23)

17. In the past 3 months, how often did you have pain?

1. Never (Go to Q23)

2. Some days

3. Most days

4. Every day

18. Thinking about the last time you had pain, how long did the pain last?

1. Some of the day

2. Most of the day

3. All of the day

19a. Thinking about the last time you had pain, how much pain did you have?

1. A little (Go to Q20)

2. A lot (Go to Q20)

3. Somewhere in between a little and a lot (Go to Q19b)

19b. Would you say the amount of pain was closer to a little, closer to a lot, or exactly in the middle?

1. Closer to a little

2. Closer to a lot

3. Exactly in the middle

20. How old were you when the pain began?

_____ Age in years

21. How much does your pain limit your ability to carry out daily activities?

1. Not at all

2. A little

3. A lot

4. Completely

22. Which of the following activities, if any, are you unable to do, or find it hard to do, because of the pain?

A. Working to support you or your family?

1. Yes

2. No

B. Working outside the home to earn an income?

1. Yes

2. No

C. Going to school or achieving your education goals?

1. Yes

2. No

D. Participating in leisure or social activities?

1. Yes

2. No

E. Getting out with friends or family?

1. Yes

2. No

F. Doing household chores such as cooking and cleaning?

1. Yes

2. No

G. Using transportation to get to places you want to go?

1. Yes

2. No

H. Participating in religious activities?

1. Yes

2. No

I. Participating in community events or gatherings?

1. Yes

2. No

FATIGUE

23. In the past 3 months, how often did you feel very tired or exhausted?

1. Never

2. Some days

3. Most days

4. Every day

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