Adult Rhinoconjunctivitis Quality of Life Questionnaire
We would like you to think of ways in which your nose/eye symptoms trouble you in your life.
We are particularly interested in activities that you do but which are limited by your nose/eye
symptoms. You may be limited because you do these activities less often, or less well, or
because they are less enjoyable. These should be activities which you do frequently and which
are important in your day-to-day life. These should also be activities that you intend to do
regularly throughout the study.
Here is a list of activities in which some people with nose/eye symptoms are limited. We hope
that this will help you to identify the 3 most important activities in which you have been limited
by your nose/eyes symptoms during the last week.
1. BICYCLING
2. READING
3. SHOPPING
4. DOING HOME MAINTENANCE
5. DOING YOUR HOMEWORK
6. GARDENING
7. WATCHING TV
8. EXERCISING OR WORKING OUT
9. GOLF
10. USING A COMPUTER
11. MOWING THE LAWN
12. PLAYING WITH PETS
13. PLAYING WITH CHILDREN OR
GRANDCHILDREN
14. PLAYING SPORTS
15. DRIVING
Write your 3 activities on the next page.
16. SINGING
17. DOING REGULAR SOCIAL ACTIVITIES
18. HAVING SEXUAL RELATIONS
19. TENNIS
20. TALKING
21. EATING
22. VACUUMING
23. VISITING FRIENDS OR RELATIVES
24. GOING FOR A WALK
25. WALKING THE DOG
26. OUTDOOR ACTIVITIES
27. CARRYING OUT YOUR ACTIVITIES AT WORK
28. SITTING OUTDOORS
29. TAKING CHILDREN TO THE PARK
Duke Department of Surgery | Division of Otolaryngology-Head and Neck Surgery
ACTIVITIES
Please write your 3 most important activities on the lines below and then tell us how much you
have been troubled by your nose/eye symptoms in each activity during the last week by making
an X in the box with the appropriate rating.
How troubled have you been by each of these activities during the last week as a result of your
nose/eye symptoms?
Activities
1.
2.
3.
SLEEP
Not
Troubled
0
Hardly
Troubled
At All
1
Somewhat
Troubled
2
Moderately
Troubled
3
Quite A
Bit
Troubled
4
Very
Troubled
5
Extremely
Troubled
6
Activity
Not
Done
9
How troubled have you been by each of these sleep problems during the last week as a result
of your nose/eye symptoms?
4. Difficulty getting to
sleep
5. Wake up during
the night
6. Lack of a good
night's sleep
Not
Troubled
0
Hardly
Troubled
At All
1
Somewhat
Troubled
2
Moderately
Troubled
3
Quite A
Bit
Troubled
4
Very
Troubled
5
Extremely
Troubled
6
Duke Department of Surgery | Division of Otolaryngology-Head and Neck Surgery
NON-NOSE/EYE SYMPTOMS
How troubled have you been by these problems during the last week as a result of your
nose/eye symptoms?
7. Fatigue
8. Thirst
9. Reduced
Productivity
10. Tiredness
11. Poor
Concentration
12. Headache
13. Worn Out
Not
Troubled
0
Hardly
Troubled
At All
1
Somewhat
Troubled
2
Moderately
Troubled
3
Quite A
Bit
Troubled
4
Very
Troubled
5
Extremely
Troubled
6
PRACTICAL PROBLEMS
How troubled have you been by each of these problems during the last week as a result of your
nose/eye symptoms?
14. Inconvenience of
having to carry
tissues or
handkerchief
15. Need to rub
nose/eyes
16. Need to blow
nose repeatedly
Not
Troubled
0
Hardly
Troubled
At All
1
Somewhat
Troubled
2
Moderately
Troubled
3
Quite A
Bit
Troubled
4
Very
Troubled
5
Extremely
Troubled
6
Duke Department of Surgery | Division of Otolaryngology-Head and Neck Surgery
NASAL SYMPTOMS
How troubled have you been by each of these symptoms during the last week?
Not Hardly Somewhat Moderately Quite A Very
Extremely
17. Stuffy/blocked
18. Runny
19. Sneezing
20. Post nasal drip
EYE SYMPTOMS
Troubled
0
Troubled
At All
1
Troubled
2
Troubled
3
Bit
Troubled
4
Troubled
5
Troubled
6
How troubled have you been by each of these symptoms during the last week?
Not Hardly Somewhat Moderately Quite A Very
Extremely
21. Itchy eyes
22. Watery eyes
23. Sore eyes
24. Swollen eyes
Troubled
0
Troubled
At All
1
Troubled
2
Troubled
3
Bit
Troubled
4
Troubled
5
Troubled
6
Duke Department of Surgery | Division of Otolaryngology-Head and Neck Surgery
EMOTIONAL
How often during the last week have you been troubled by these emotions as a result of your
nose/eye symptoms?
25. Frustrated
26. Impatient or
restless
27. Irritable
28. Embarrassed by
your symptoms
None of
the Time
0
Hardly
Any
Time at
All
1
A Small
Part of the
Time
2
Some of
the Time
3
A Good
Part of
the Time
4
Most of
the Time
5
All of the
Time
6
Duke Department of Surgery | Division of Otolaryngology-Head and Neck Surgery
Bạn đang đọc truyện trên: Truyen2U.Pro