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First Name*

Last Name*

Birthdate*
Date Format: MM slash DD slash YYYY
Your Daily Activities
PATIENT INSTRUCTIONS: Indicate your response by selecting one box per question.
Can you use the telephone...*
- without help, including looking up and dialing;
- with some help (can answer phone or dial operator in an emergency, but need a special phone or help in getting the number or dialing); or
- are you completely unable to use the telephone?
Can you get to places out of walking distance...*
- without help (can travel alone on busses, taxis, or drive your own car);
- with some help (need someone to help you or go with you when traveling); or
- are you unable to travel unless emergency arrangements are made for a specialized vehicle like an ambulance?
Can you go shopping for groceries or clothes (assuming you have transportation)...*
- without help (taking care of all shopping needs yourself, assuming you have transportation);
- With some help (need someone to go with you on all shopping trips); or
- are you completely unable to do any shopping?
Can you prepare your own meals...*
- without help (plan and cook full meals yourself);
- with some help (can prepare some things but unable to cook full meals yourself); or
- are you completely unable to prepare any meals?
Can you do your housework...*
- without help (can clean floors, etc.);
- with some help (can do light housework but need help with heavy work); or
- are you completely unable to do any housework?
Can you take your own medicines...*
- without help (in the right doses at the right time);
- with some help (able to take medicine if someone prepares it for you and/or reminds you to take it); or
- are you completely unable to take your medicines?
Can you handle your own money...*
- without help (write checks, pay bills, etc.);
- with some help (manage day-to-day buying but need help with managing your checkbook and paying your bills); or
- are you completely unable to handle money?
Does your health limit you in these activities?
The following items are activities you might do during a typical day. Does your health limit you in these activities? (Mark an X in the box on each line that best reflects your situation.)
Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports*
- Limited a lot
- Limited a little
- Not limited at all
Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf*
- Limited a lot
- Limited a little
- Not limited at all
Lifting or carrying groceries*
- Limited a lot
- Limited a little
- Not limited at all
Climbing several flights of stairs*
- Limited a lot
- Limited a little
- Not limited at all
Climbing one flight of stairs*
- Limited a lot
- Limited a little
- Not limited at all
Bending, kneeling, or stooping*
- Limited a lot
- Limited a little
- Not limited at all
Walking more than a mile*
- Limited a lot
- Limited a little
- Not limited at all
Walking several blocks*
- Limited a lot
- Limited a little
- Not limited at all
Walking one block*
- Limited a lot
- Limited a little
- Not limited at all
Bathing or dressing yourself*
- Limited a lot
- Limited a little
- Not limited at all
Current Health Rating
Which one of the following phrases best describes you at this time?*
Falls
How many times have you fallen in the last 6 months?*
Medications
Are you taking any medications?*
- Yes
- No
How many prescribed medications are you taking?*
How many over-the-counter medications are you taking?*
How many herbs and vitamins are you taking?*

Your Health
Patient Instructions: Do you have any of the following illnesses at the present time, and if so, how much does it interfere with your activities: Not at All, A Little, or A Great Deal? (Select the box that best reflects your answer.)
Other cancers or leukemia*
- No
- Yes
How much does it interfere with your activities?*
- Not at All
- A Little
- A Great Deal
Arthritis or rheumatism*
- No
- Yes
How much does it interfere with your activities?*
- Not at All
- A Little
- A Great Deal
Glaucoma*
- No
- Yes
How much does it interfere with your activities?*
- Not at All
- A Little
- A Great Deal
Emphysema or chronic bronchitis*
- No
- Yes
How much does it interfere with your activities?*
- Not at All
- A Little
- A Great Deal
High blood pressure*
- No
- Yes
How much does it interfere with your activities?*
- Not at All
- A Little
- A Great Deal
Heart trouble*
- No
- Yes
How much does it interfere with your activities?*
- Not at All
- A Little
- A Great Deal
Circulation trouble in arms or legs*
- No
- Yes
How much does it interfere with your activities?*
- Not at All
- A Little
- A Great Deal
Diabetes*
- No
- Yes
How much does it interfere with your activities?*
- Not at All
- A Little
- A Great Deal
Stomach or intestinal disorders*
- No
- Yes
How much does it interfere with your activities?*
- Not at All
- A Little
- A Great Deal
Osteoporosis*
- No
- Yes
How much does it interfere with your activities?*
- Not at All
- A Little
- A Great Deal
Liver disease*
- No
- Yes
How much does it interfere with your activities?*
- Not at All
- A Little
- A Great Deal
Kidney disease*
- No
- Yes
How much does it interfere with your activities?*
- Not at All
- A Little
- A Great Deal
Stroke*
- No
- Yes
How much does it interfere with your activities?*
- Not at All
- A Little
- A Great Deal
Depression*
- No
- Yes
How much does it interfere with your activities?*
- Not at All
- A Little
- A Great Deal
How is your eyesight (with glasses or contacts)?*
- Excellent
- Good
- Fair
- Poor
- Totally blind
How much does it interfere with your activities?*
- Not at All
- A Little
- A Great Deal
How is your hearing (with a hearing aid, if needed)?*
- Excellent
- Good
- Fair
- Poor
- Totally deaf
How much does it interfere with your activities?*
- Not at All
- A Little
- A Great Deal
Do you have any other physical problems or illnesses (other than those listed above) at the present time that seriously affect your health?*
- No
- Yes
If the above answer is yes, please specify the physical problem/illness:
How much does it interfere with your activities?*
- Not at All
- A Little
- A Great Deal
Nutritional Status
Have you lost weight involuntarily over the past 6 months?*
- No
- Yes
If yes, how much?
Pounds or Kilograms?
Health Questionnaire
INSTRUCTIONS: These questions are about how you have been feeling within the past month. Please mark an "X" in the box on each line that best reflects your situation. How much of the time during the past month:
has your daily life been full of things that were interesting to you?*
- 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
did you feel depressed?*
- 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
have you felt loved and wanted?*
- 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
have you been in firm control of your behavior, thoughts, emotions, feelings?*
- 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
have you felt tense or high-strung?*
- 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
have you felt calm or peaceful?*
- 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
have you felt emotionally stable?*
- 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
have you felt restless, fidgety, or impatient?*
- 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
have you felt downhearted and blue?*
- 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
have you been moody, or brooded about things?*
- 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
have you felt cheerful, light-hearted?*
- 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
have you been in low or very low spirits?*
- 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
were you a happy person?*
- 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
did you feel you had nothing to look forward to?*
- 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
have you felt so down in the dumps that nothing could cheer you up?*
- 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
have you been anxious or worried?*
- 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
have you been a very nervous person?*
- 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

Social Activities
During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)?*
- 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
Compared to your usual level of social activity, has your social activity during the past 6 months decreased, stayed the same, or increased because of a change in your physical or emotional condition?*
- Much less socially active than before
- Somewhat less socially active than before
- About as socially active as before
- Somewhat more socially than before
- Much more socially active than before
Compared to others your age, are your social activities more or less limited because of your physical health or emotional problems?*
- Much more limited than others
- Somewhat more limited than others
- About the same as others
- Somewhat less limited than others
- Much less limited than others
Social Support
INSTRUCTIONS: People sometimes look to others for companionship, assistance or other types of support. How often is each of the following kinds of support available to you if you need it? (Mark an X in the box on each line that best reflects your situation.)
Someone to help if you were confined to bed.*
- None of the Time
- A Little of the Time
- Some of the Time
- Most of the Time
- All of the Time
Someone you can count on to listen to you when you need to talk.*
- None of the Time
- A Little of the Time
- Some of the Time
- Most of the Time
- All of the Time
Someone to take you to the doctor if you needed it.*
- None of the Time
- A Little of the Time
- Some of the Time
- Most of the Time
- All of the Time
Someone to give you information to help you understand a situation.*
- None of the Time
- A Little of the Time
- Some of the Time
- Most of the Time
- All of the Time
Someone to confide in or talk to about yourself or your problem.*
- None of the Time
- A Little of the Time
- Some of the Time
- Most of the Time
- All of the Time
Someone to prepare your meals if you were unable to do it yourself.*
- None of the Time
- A Little of the Time
- Some of the Time
- Most of the Time
- All of the Time
Someone whose advice you really want.*
- None of the Time
- A Little of the Time
- Some of the Time
- Most of the Time
- All of the Time
Someone to give you good advice about a crisis.*
- None of the Time
- A Little of the Time
- Some of the Time
- Most of the Time
- All of the Time
Someone to help you with daily chores if you were sick.*
- None of the Time
- A Little of the Time
- Some of the Time
- Most of the Time
- All of the Time
Someone to share your most private worries and fears with.*
- None of the Time
- A Little of the Time
- Some of the Time
- Most of the Time
- All of the Time
Someone to turn to for suggestions about how to deal with a personal problem.*
- None of the Time
- A Little of the Time
- Some of the Time
- Most of the Time
- All of the Time
Someone who understands your problems.*
- None of the Time
- A Little of the Time
- Some of the Time
- Most of the Time
- All of the Time
Spirituality/Religion
Please answer the following questions about your religious beliefs and/or involvement. Select the answer that best reflects your situation.
How often do you attend church, synagogue, or other religious meetings?*
- More than once per week
- Once a week
- A few times a month
- A few times a year
- Once a year or less
- Never
How often do you spend time in private religious activities, such as prayer, meditation or Bible study?*
- More than once a day
- Daily
- Two or more times per week
- Once a week
- A few times a month
- Rarely or never
The following section contains 3 statements about your religious belief or experience. Please select the extent to which each statement is true or not true for you.
In my life, I experience the presence of the Divine (i.e., God).*
- Definitely true of me
- Tends to be true
- Unsure
- Tends not to be true
- Definitely not true
My religious beliefs are what really lie behind my whole approach to life.*
- Definitely true of me
- Tends to be true
- Unsure
- Tends not to be true
- Definitely not true
I tried hard to carry my religion over into all other dealings in my life.*
- Definitely true of me
- Tends to be true
- Unsure
- Tends not to be true
- Definitely not true
Your Feelings
Do you often feel sad or depressed?*
- No
- Yes
How would you describe you level of anxiety, on the average? Please select the number (0-10) best reflecting your response to the following that describes your feelings during the past week, including today.*
Data Collection
Information gained from this questionnaire may be used for future clinical research and/or data collection by Nebraska Cancer Specialists. NO patient identifiers will be associated with the data retrieved.

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