Kwaliteit van Leven vragenlijst 1 METEX studie
Quality of Life
Questionnaire 3
4 weeks after randomisation
Graag in laten vullen door geincludeerde patiënt METEX studie
Patient Identification Number Datum van invullen
Patient registration label
Kwaliteit van Leven vragenlijst 2 METEX studie
SF-36 HEALTH SURVEY
INSTRUCTIONS: This survey asks for your views about your health. This information will help keep track of how you feel end how well you are able to do your usual activities.
Answer every question by marking the anser as indicated. If you are unsure about how to answer a question, please give the best answer you can.
1. In general how would you say your health is:
(circle one)
Excellent ... 1
Very good ... 2
Good ...… 3
Fair ... 4
Poor ... 5
2. Compared to one year ago, how would you rate your health in general now? (circle one) Much better now than one year ago ... 1
Somewhat better now than one year ago... 2
About the same as one year ago ……… ... 3
Somewhat worse now than one year ago... 4
Much worse now than one year ago ... 5
Kwaliteit van Leven vragenlijst 3 METEX studie 3. The following items are about activities you might do during a typical day. Does your
health now limit you in these activities? If so, how much?
(omcirkel één cijfer op elke regel)
Activities Yes,
Limited a lot
Yes, Limtited a
little
No, not limited at all
a. Vigorous activities such as running, lifting heavy objects, participating in strenuous
sports 1 2 3
b. Moderate activities such as moving a table, pushing a vacuum cleaner, bowling, or
playing golf 1 2 3
c. Lifting or carrying groceries 1 2 3
d. Climbing several flights of stairs 1 2 3
e. Climbing one flight of stairs 1 2 3
f. Bending, kneeling, or stooping 1 2 3
g. Walking more than a mile 1 2 3
h. Walking several blocks 1 2 3
i. Walking one block 1 2 3
j. Bathing or dressing yourself 1 2 3
4. During the past week, have you had any of the following problems with your work or other regular daily activities as a result of your physical health?
(circle one number on each line) YES NO
a. Cut down on the amount of time you spent on work or other activities 1 2
b. Accoplished less than you would like 1 2
c. Were limited in the kind of work or other activities 1 2
d. Had difficulty performing the work or other activities ( for example, it took extra effort)
1 2
Kwaliteit van Leven vragenlijst 4 METEX studie 5. During the past week, have you had any of the following problems with your work or
other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)?
(circle one number on each line) YES NO
a. Cut down the amount of time you spent on work or other activities 1 2
b. Accomplished less than you would like 1 2
c. Didn’t do work or other activities as carefully as usual 1 2
6. During the past week, to what extent has your physical health or emotional problems interfered with your normal social activities with family, friends, neighbors, or groups?
(omcirkel één cijfer)
Not at all ...…... 1
Slightly……….. 2
Moderately...………... 3
Quite a bit...………... 4
Extremely ...……... 5
7. How much bodily pain have you had during the past week? (circle one) None ...………... 1
Very mild ...………... 2
Mild ...………... 3
Moderate...………... 4
Severe ...………...…... 5
Very severe ………... 6
Kwaliteit van Leven vragenlijst 5 METEX studie 8. During the past week, how much did pain interfere with your normal work (including both
work outside the home and housework)?
(circle one)
Not at all ...…... 1
A little bit ...……... 2
Moderately...………... 3
Quite a bit...………... 4
Extremely ...……... 5
9. These questions are about how things have been with you during the past week. For each question, please give the one answer that comes closest to the way you have been feeling. How much of the time during the last week:
(circle one number on each line)
All of the time
Most of the
time
A good bit of the time
Some of the time
A little of the
time
None of the time
a. Did you feel full of pep? 1 2 3 4 5 6
b. Have you been a very nervous person?
1 2 3 4 5 6
c. Have you felt so down in the dumps
that nothing could cheer you up? 1 2 3 4 5 6
d. Have you felt calm and peaceful? 1 2 3 4 5 6
e. Did you have a lot of energy? 1 2 3 4 5 6
f. Have you felt downhearted and
blue? 1 2 3 4 5 6
g. Did you feel worn out? 1 2 3 4 5 6
h. Have you been a happy person? 1 2 3 4 5 6
i. Did you feel tired? 1 2 3 4 5 6
Kwaliteit van Leven vragenlijst 6 METEX studie 10. During the past week, how much of the time has your physical health or emotional
problems interfered with your social activities (like visiting with friends, relatives, etc.)?
(circle one)
All of the time...…... 1
Most of the time...……... 2
Some of the time...………... 3
A little of the time... 4
None of the time...……... 5
11. How TRUE or FALSE is each of the following statements for you?
(circle one number on each line)
Definitely True
Mostly True
Don’t know
Mostly False
Definitely False
a. I seem to get sich a little easier than other people
1 2 3 4 5
b. I am as healthy as
anybody I know 1 2 3 4 5
c. I expect my health to get worse
1 2 3 4 5
d. My health is excellent
1 2 3 4 5
Kwaliteit van Leven vragenlijst 7 METEX studie
In this questionnaire you will be asked about your symptoms. Would you please, for all symptoms mentioned, indicate to what extent you have been bothered by it, by circling the answer most applicable to you. The questions are related to the past week.
Example:
Have you been bothered, during the past week, by
Headaches not at all a little quite a bit very much
Have you been bothered, during the past week, by
Lack of appetite not at all a little quite a bit very much
Tiredness not at all a little quite a bit very much
Skin rash/irritation not at all a little quite a bit very much
Lack of energy not at all a little quite a bit very much
Redness of eyes not at all a little quite a bit very much
Nausea not at all a little quite a bit very much
Difficulty sleeping not at all a little quite a bit very much
Headache not at all a little quite a bit very much
Vomiting not at all a little quite a bit very much
Dizziness not at all a little quite a bit very much
Sore mouth/ pain when swallowing not at all a little quite a bit very much Decreased sexual interest not at all a little quite a bit very much
Heartburn/belching not at all a little quite a bit very much
Shivering not at all a little quite a bit very much
Tingling hands or feet not at all a little quite a bit very much
Abdominal aches not at all a little quite a bit very much
Burning/ sore eyes not at all a little quite a bit very much
Hypersensitivity to sunlight not at all a little quite a bit very much
Shortness of breath not at all a little quite a bit very much
Dry mouth not at all a little quite a bit very much
Diarrhoea not at all a little quite a bit very much
Constipation not at all a little quite a bit very much
Kwaliteit van Leven vragenlijst 8 METEX studie
This questionnaire is designed to help your doctor to know how you feel.
Read each item and place a firm tick in the box opposite the reply which comes closest to how you have been feeling in the past week.
1. I feel tense or ‘wound up’:
Most of the time
A lot of the time
Time to time, occasionally
Not at all
2. I still enjoy the things I used to enjoy:
Definitely as much
Not quite so much
Only a little
Hardly at all
3. 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
4. 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
5. 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 6. I feel cheerful:
Not at all
Not often
Sometimes
Most of the time
7. I can sit at ease and feel relaxed:
Definitely
Usually
Not often
Not at all
Kwaliteit van Leven vragenlijst 9 METEX studie 8. I feel as if I am slowed down:
Nearly all the time
Very often
Sometimes
Not at all
9. I get a sort of frightened feeling like ‘butterflies’ in the stomach
Not at all
Occasionally
Quite often
Very often
10. 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
11. I feel restless as if I have to be on the move:
Very much indeed
Quite a lot
Not very much
Not at all
12. 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
13. I get sudden feelings of panic:
Very often indeed
Quite often
Not very often
Not at all
14. I can enjoy a good book or radio or TV programme:
Often
Sometimes
Not often
Very seldom
