QUAL-E 2005 (Steinhauser et al.)
Measuring the Quality of Life of Seriously Ill Patients
I’d like you to think back over the last month. Please tell me the three physical symptoms or problems that
have bothered you the most during that time. Some examples are pain, nausea, lack of energy, confusion,
depression, anxiety, and shortness of breath.
Symptom #1_________________________ Symptom #3_________________________
Symptom #2_________________________
• If no symptoms were elicited, then state the following:
So, just to be sure, over the last month, you have had no physical or emotional symptoms that bothered
you.
If correct, skip to question #5.
Which of these symptoms or problems has bothered you the most this past week?
1. During the last week, how often have you experienced ________________?
Rarely
1
A few times
2
Fairly often
3
Very often
4
Most of the time
5
2. During the last week, on average, how severe has ________________ been?
Very mild
1
Mild
2
Moderate
3
Severe
4
Very severe
5
3. During the last week, how much has ________________ interfered with your ability to enjoy your life?
Not at all
1
A little bit
2
A moderate amount
3
Quite a bit
4
Completely
5
4. How worried are you about ________________ occurring in the future?
Not at all
1
A little bit
2
A moderate amount
3
Quite a bit
4
Completely
5
5. In general, how important are your PHYSICAL SYMPTOMS OR PROBLEMS to your overall quality of
life?
Not at all
1
A little bit
2
A moderate amount
3
Quite a bit
4
Completely
5
1