OMB# 0925-XXX;Exp: XX/XXXX
Neuro-QOL
Sociodemographic & Clinical Forms Date Last Modified
Neuro-QOL Adult Sociodemographic Form
On average, it takes 30 minutes to complete the Neuro-QOL survey
1
|
What is your telephone area code (where you currently live)?
|
__________________
|
2 |
What is your age? |
__________________
|
3 |
What is your gender? |
1=Male
|
4 |
Are you of Spanish/Hispanic/Latino origin? |
0=No
|
5
|
What is your racial or ethnic background? (Please mark all that apply) |
1=White
|
6 |
What is your current relationship status? |
1=Never
Married
|
7
|
What is the highest grade in school that you completed? |
1=5th
grade or less
|
8
|
What is your current occupational status? (Please mark all that apply) |
1=Homemaker
|
9
|
What is your family household income (from all sources)? |
1=Less
than $20,000
|
10 |
What is your height? |
______(feet) _______(inches) |
11 |
What is your weight in pounds? |
___________________
|
12 |
Mobility |
1=I
have no problems in walking about
|
13 |
Self-Care |
1=I
have no problems with self-care
|
14
|
Usual Activities (e.g. work, study, housework, family or leisure activities) |
1=I
have no problems with performing my usual activities
|
15
|
Please indicate which statement below best describes your current activity level |
0=I
have normal activity, without symptoms waking
day
|
16 |
Pain/Discomfort |
1=I
have no pain or discomfort
|
17 |
Anxiety/Depression |
1=I
am not anxious or depressed
|
18
|
In the past 30 days, have you used or taken medication for which a prescription is needed? Include only those products prescribed by a health professional such as a doctor or dentist. |
0=No
|
19
|
How many different times did you stay in any hospital overnight or longer during the past 12 months? |
_______________
|
20
|
During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities such as self-care, work, or recreation? |
________________
|
Neuro-QOL Adult Clinical Form
***Note that each patient will not necessarily complete each of the following questions, but only those that apply***
1
|
Have you ever been told by a doctor or a health professional that you have high blood pressure (hypertension)? |
0
= No |
2
|
Are any of your current activities limited by your high blood pressure (hypertension)? |
0
= No |
3
|
Have you ever been told by a doctor or a health professional that you had chest pain (angina)? |
0
= No |
4
|
Are any of your current activities limited by your chest pain (angina)? |
0
= No |
5
|
Have you ever been told by a doctor or a health professional that you have hardening of the arteries (coronary artery disease)? |
0
= No |
6
|
Are any of your current activities limited by your hardening of the arteries (coronary artery disease)? |
0
= No |
7
|
Have you ever been told by a doctor or a health professional that you have heart failure or congestive heart failure? |
0
= No |
8
|
Are any of your current activities limited by your heart failure or congestive heart failure? |
0
= No |
9
|
Have you ever been told by a doctor or a health professional that you had a heart attack (myocardial infarction)? |
0
= No |
10
|
Are any of your current activities limited by your heart attack (myocardial infarction)? |
0
= No |
11
|
Have you ever been told by a doctor or a health professional that you had a stroke or transient ischemic attack (TIA)? |
0
= No |
12
|
Are any of your current activities limited by your stroke or transient ischemic attack (TIA)? |
0
= No |
13
|
How many years ago did you have your stroke or transient ischemic attack (TIA)? |
_____________ |
14
|
Compare your overall stroke-related symptoms now with what you experienced one year ago. Are they better, worse or about the same? |
1=Better |
15
|
Have you ever been told by a doctor or a health professional that you have migraines or severe headaches? |
0
= No |
16
|
Are any of your current activities limited by your migraines or severe headaches? |
0
= No |
17
|
Have you ever been told by a doctor or a health professional that you have diabetes or high blood sugar or sugar in your urine? |
0
= No |
18
|
Are any of your current activities limited by your diabetes or high blood sugar or sugar in your urine? |
0
= No |
19 |
How many years have you had diabetes? |
______________ |
20
|
Has your diabetes caused a problem for any of the following parts of your body: eyes, kidneys or feet? |
0=No |
21 |
Have you ever been hospitalized because of your diabetes? |
0=No |
22
|
Have you ever been told by a doctor or a health professional that you have cancer (other than non-melanoma skin cancer)? |
0
= No |
23
|
Are any of your current activities limited by your cancer (other than non-melanoma skin cancer)? |
0
= No |
24
|
Please select your "primary" cancer diagnosis from the list below (usually where the cancer started) |
1=Bone/muscle (e.g. Sarcomas) 2=Brain 3=Breast 4=Melanoma 5=Esophagus or Stomach 6=Gynecologic (e.g. Cervical, Ovarian, Uterine) 7=Head/Neck 8=Hodgkin's Lymphoma 9=Leukemia 10=Liver 11=Lung 12=Colon or Rectum 13 =Multiple Myeloma 14=Non-Hodgkin's Lymphoma 15=Non Melanoma Skin 16=Pancreas 17=Prostate 18=Urologic(e.g. Bladder, Kidney, Testis) 19=Unknown or Other |
25
|
Have you had a recurrence of your cancer (i.e., has your cancer come back)? |
0=No |
26 |
Has your cancer spread to any lymph nodes? |
0=No |
27
|
Has your cancer spread to another part of your body (other than to any lymph nodes)? |
0=No |
28
|
Do you currently have any numbness, tingling, or pain in your hands or feet? |
0=No |
29
|
Have you ever been told by a doctor or a health professional that you have depression? |
0
= No |
30 |
Are any of your current activities limited by your depression? |
0
= No |
31
|
Have you received treatment from a mental health specialist (for example a psychiatrist, psychologist, social worker, or other therapist) for your depression? |
0=No |
32
|
To what extent does your depression interfere with your relationships with family or friends? |
0=Not at all 1=A little bit 2=Somewhat 3= Quite a bit 4=Very much |
33
|
To what extent does your depression interfere with maintaining your responsibilities at work or at home? |
0=Not
at all |
34
|
Have you ever been told by a doctor or a health professional that you have anxiety? |
0
= No |
35 |
Are any of your current activities limited by your anxiety? |
0
= No |
36
|
Have you received treatment from a mental health specialist (for example a psychiatrist, psychologist, social worker, or other therapist) for your anxiety? |
0=No |
37
|
To what extent does your anxiety interfere with your relationships with family or friends? |
0=Not
at all |
38
|
To what extent does your anxiety interfere with maintaining your responsibilities at work or at home? |
0=Not
at all |
39
|
Have you ever been told by a doctor or a health professional that you have an alcohol or drug problem? |
0
= No |
40
|
Are any of your current activities limited by your alcohol or drug problem? |
0
= No |
41
|
Have you received treatment from a mental health specialist (for example a psychiatrist, psychologist, social worker, or other therapist) for your alcohol or drug problem? |
0=No 1=Yes |
42
|
To what extent does your alcohol or drug problem interfere with your relationships with family and friends? |
0=Not
at all |
43
|
To what extent does your alcohol or drug problem interfere with maintaining your responsibilities at work or at home? |
0=Not
at all |
44
|
Have you ever been told by a doctor or a health professional that you have a sleep disorder? |
0
= No |
45
|
Are any of your current activities limited by your sleep disorder? |
0
= No |
46
|
What type of sleep disorder was diagnosed? (Please mark all that apply) |
1=Insomnia |
47 |
Has your sleep disorder been treated? |
0=No |
48
|
What type of treatment did you receive? (Please mark all that apply) |
1=Medication 2=CPAP, Bilevel pressure 3=Oral appliance 4=Behavioral 5=Over-the-counter or non-prescription treatment 6=Other |
49 |
Did the treatment help you? |
0=Not
at all |
50
|
Have you ever been told by a doctor or a health professional that you have HIV or AIDS? |
0
= No |
51 |
Are any of your current activities limited by your HIV or AIDS? |
0
= No |
52
|
Have you ever been told by a doctor or a health professional that you have a spinal cord injury? |
0
= No |
53
|
Are any of your current activities limited by your spinal cord injury? |
0
= No |
54 |
How long ago was your spinal cord injury? |
1=Less
than two years ago |
55 |
At what level is your spinal cord injury? |
1=Lumbar |
56 |
Is your spinal cord injury complete or incomplete? |
1=Complete |
57
|
Have you ever been told by a doctor or a health professional that you have Multiple Sclerosis (MS)? |
0 = No 1 = Yes |
58
|
Are any of your current activities limited by your Multiple Sclerosis (MS)? |
0
= No |
59 |
How long ago was your MS diagnosed? |
1=Less
than two years ago |
60
|
Compare your overall symptoms now with what you experienced one year ago. Is your MS better, worse or about the same? |
1=Better |
61
|
Are you taking disease-modifying drugs for your MS such as Avonex, Betaseron, Copaxone or Rebif? |
0=No |
62
|
Have you ever been told by a doctor or a health professional that you had Parkinson's Disease? |
0
= No |
63
|
Are any of your current activities limited by your Parkinson's Disease? |
0
= No |
64 |
How long ago was your Parkinson's disease diagnosed? |
1=Less
than two years ago |
65
|
Compare your overall symptoms now with what you experienced one year ago. Is your Parkinson's disease better, worse or about the same? |
1=Better |
66
|
Have you ever been told by a doctor or a health professional that you had epilepsy? |
0
= No |
67 |
Are any of your current activities limited by your epilepsy? |
0 = No 1 = Yes |
68 |
How long ago was your epilepsy diagnosed? |
1=Less
than two years ago |
69
|
Compare your overall symptoms now with what you experienced one year ago. Is your epilepsy better, worse or about the same? |
1=Better |
70
|
Have you ever been told by a doctor or a health professional that you had Amyotrophic Lateral Sclerosis (ALS) or Lou Gehrig's disease? |
0
= No |
71
|
Are any of your current activities limited by your Amyotrophic Lateral Sclerosis (ALS) or Lou Gehrig's disease? |
0
= No |
72 |
How long ago was your ALS diagnosed? |
1=Less
than 1 year ago |
73
|
Compare your overall symptoms now with what you experienced one year ago. Is your ALS better, worse or about the same? |
1=Better |
74 |
Do you have children under 20? |
0
= No |
75
|
Have you ever been told by a doctor or a health professional that your child had epilepsy? |
0
= No |
76 |
Are any of your child's current activities limited by epilepsy? |
0
= No |
77 |
How long ago was your child's epilepsy diagnosed? |
1=Less than two years ago 2=Between two and five years ago 3=Between six and ten years ago 4=Between 11 and 20 years ago 5=More than 20 years ago |
78
|
Compare your child's overall symptoms now with what he/she experienced one year ago. Is your child's epilepsy better, worse or about the same? |
1=Better |
79
|
Have you ever been told by a doctor or a health professional that your child had muscular dystrophy? |
0
= No |
80
|
Are any of your child's current activities limited by muscular dystrophy? |
0
= No |
81
|
How long ago was your child's muscular dystrophy diagnosed? |
1=Less
than two years ago |
82
|
Compare your child's overall symptoms now with what he/she experienced one year ago. Is your child's muscular dystrophy better, worse or about the same? |
1=Better |
Neuro-QOL Sociodemographic Form (PEDIATRIC VERSION
1
|
What is your telephone area code (where you currently live) |
__________
|
2 |
How old are you? |
__________
|
3 |
What is your gender? |
1=Male
|
4 |
Are you of Spanish/Hispanic/Latino origin? |
0=No
|
5
|
What is your racial or ethnic background? (Please mark all that apply) |
1=White |
6 |
Are you attending school now (including home school)? |
1=Yes 2=No
If yes, what grade are you in? __________
If no, what is the highest grade in school that you completed?_________ |
7
|
What is your current occupational status? (Please mark all that apply) |
4=Part-time student 5=none of above |
8 |
What is your height? |
______(feet) _______(inches) |
9 |
What is your weight in pounds? |
_____________ |
10
|
How many different times did you stay in any hospital overnight or longer during the past 12 months? |
|
File Type | application/msword |
File Title | Neuro-QOL Online Sociodemographic Form |
Author | victord |
Last Modified By | CSMoy |
File Modified | 2007-12-20 |
File Created | 2007-12-20 |