EORTC-QLQ-C30-(version-3)_英文版

PORTEC-3QualityoflifequestionnairePORTEC-3trialnumber:|__|__|__|Page1of4EORTCQLQ-C30(version3)Weareinterestedinsomethingsaboutyouandyourhealth.Pleaseanswerallofthequestionsyourselfbycirclingthenumberthatbestappliestoyou.Therearenorightorwronganswers.Theinformationthatyouprovidewillremainstrictlyconfidential.Pleasefillinyourfirstinitial:|____|Yourbirthdate(Day,Month,Year):|__|__||__|__||__|__|__|__|Today'sdate(Day,Month,Year):|__|__||__|__||__|__|__|__|_______________________________________________________________________________________NotatAQuiteVeryAllLittleaBitMuch1.Doyouhaveanytroubledoingstrenuousactivities,likecarryingaheavyshoppingbagorasuitcase?12342.Doyouhaveanytroubletakingalongwalk?12343.Doyouhaveanytroubletakingashortwalkoutsideofthehouse?12344.Doyouneedtostayinbedorachairduringtheday?12345.Doyouneedhelpwitheating,dressing,washingyourselforusingthetoilet?1234Duringthepastweek:NotatAQuiteVeryAllLittleaBitMuch6.Wereyoulimitedindoingeitheryourworkorotherdailyactivities?12347.Wereyoulimitedinpursuingyourhobbiesorotherleisuretimeactivities?12348.Wereyoushortofbreath?12349.Haveyouhadpain?123410.Didyouneedtorest?123411.Haveyouhadtroublesleeping?123412.Haveyoufeltweak?123413.Haveyoulackedappetite?123414.Haveyoufeltnauseated?123415.Haveyouvomited?1234PleasegoontothenextpagePORTEC-3QualityoflifequestionnairePORTEC-3trialnumber:|__|__|__|Page2of4Duringthepastweek:NotatAQuiteVeryAllLittleaBitMuch16.Haveyoubeenconstipated?123417.Haveyouhaddiarrhea?123418.Wereyoutired?123419.Didpaininterferewithyourdailyactivities?123420.Haveyouhaddifficultyinconcentratingonthings,likereadinganewspaperorwatchingtelevision?123421.Didyoufeeltense?123422.Didyouworry?123423.Didyoufeelirritable?123424.Didyoufeeldepressed?123425.Haveyouhaddifficultyrememberingthings?123426.Hasyourphysicalconditionormedicaltreatmentinterferedwithyourfamilylife?123427.Hasyourphysicalconditionormedicaltreatmentinterferedwithyoursocialactivities?123428.Hasyourphysicalconditionormedicaltreatmentcausedyoufinancialdifficulties?1234Forthefollowingquestionspleasecirclethenumberbetween1and7thatbestappliestoyou:29.Howwouldyourateyouroverallhealthduringthepastweek?1234567VerypoorExcellent30.Howwouldyourateyouroverallqualityoflifeduringthepastweek?1234567VerypoorExcellent©Copyright1995EORTCQualityofLifeGroup.Allrightsreserved.Version3.0PORTEC-3QualityoflifequestionnairePORTEC-3trialnumber:|__|__|__|Page3of4EORTCQLQ–CX24Patientssometimesreportthattheyhavethefollowingsymptomsorproblems.Pleaseindicatetheextenttowhichyouhaveexperiencedthesesymptomsorproblems,pleaseanswerbycirclingthenumberthatbestappliestoyou.Duringthepastweek:NotAQuiteVeryatalllittleabitmuch31.Haveyouhadcrampsinyourabdomen?123432.Haveyouhaddifficultyincontrollingyourbowels?123433.Haveyouhadbloodinyourstools(motions)?123434.Didyoupasswater/urinefrequently?123435.Haveyouhadpainoraburningfeelingwhenpassingwater/urinating?123436.Haveyouhadleakingofurine?123437.Haveyouhaddifficultyemptyingyourbladder?123438.Haveyouhadswellinginoneorbothlegs?123439.Haveyouhadpaininyourlowerback?123440.Haveyouhadtinglingornumbnessinyourhandsorfeet?123441.Haveyouhadirritationorsorenessinyourvaginaorvulva?123442.Haveyouhaddischargefromyourvagina?123443.Haveyouhadabnormalbleedingfromyourvagina?123444.Haveyouhadhotflushesand/orsweats?123445.Haveyoufeltphysicallylessattractiveasaresultofyourdiseaseortreatment?123446.Haveyoufeltlessfeminineasaresultofyourdiseaseortreatment?123447.Haveyoufeltdissatisfiedwithyourbody?1234PleasegoontothenextpagePORTEC-3QualityoflifequestionnairePORTEC-3trialnumber:|__|__|__|Page4of4Duringthepast4weeks:NotAQuiteVeryatalllittleabitmuch48.Haveyouworriedthatsexwouldbepainful?123449.Haveyoubeensexuallyactive?1234AnswerthesequestionsonlyifyouhavebeenNotAQuiteVerysexuallyactiveduringthepast4weeks:atalllittleabitmuch50.Hasyourvaginafeltdryduringsexualactivity?123451.Hasyourvaginafeltshort?123452.Hasyourvaginafelttight?123453.Haveyouhadpainduringsexualintercourseorothersexualactivity?123454.Wassexualactivityenjoyableforyou?1234EORTCQLQ-OV28(subscale)Duringthepastweek:NotatAQuiteVeryAllLittleaBitMuch55.Didyouhaveabloatedfeelinginyourabdomen/stomach?123456.Wereyoutroubledbypassingwind/gas/flatulence?123457.Haveyoulostanyhair?123458.Answerthisquestiononlyifyouhadanyhairloss:Wereyouupsetbythelossofyourhair?123459.Didfoodanddrinktastedifferentfromusual?123460.Haveyouhadtinglinghandsorfeet?123461.Haveyouhadnumbnessinyourfingersortoes?123462.Haveyoufeltweakinyourarmsorlegs?123463.Didyouhaveachesorpainsinyourmusclesorjoints?123464.Didyouhaveproblemswithhearing?1234©CopyrightEORTCQualityofLifeGroup.Allrightsreserved