SCORE CARD - SCORES WILL APPEAR AS FORM IS COMPLETED
ESRD-targeted Areas
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36-item health survey (SF_36)
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NOTE: Quality of Life is difficult to measure and quantify. Sadly, items that are difficult to access are ignored as performance measures. Here, we bring to light the Kidney Disease Quality of Life form created by the Rand Corporation. This is a sample form, only. No data is being tabulated or scored. Use this form to better understand how one can access quality of life.
Created for web by Stephen Z. Fadem, M.D., FACP, FASN

KIDNEY DISEASE AND QUALITY OF LIFE

SHORT FORM QUESTIONNAIRE

(KDQOL-SFTM)

© RAND 1995,1996,1997

The KDQOL-SFTM was supported in part by an unrestricted grant from Amgen to RAND, and a subgrant from the University of Arizona to RAND, and a grant from Baxter Healthcare Corporation.

Hays, R.D., Kallich, J.D., Mapes, D.L., Coons, S.J., Amin, N., & Carter, W.B. (1995) Kidney Disease Quality of Life Short Form (KDQOL-SFTM), Version 1.3: A Manual for Use and Scoring. Santa Monica, CA: RAND, P-7994

INSTRUCTIONS FOR FILLING OUT SURVEY
  1. This survey asks for your views about your health. This information will help keep track of how you feel and how well you are able to do your usual activities.
  2. This survey includes a wide variety of questions about your health and your life. We are interested in how you feel about eachof these issues.
  3. Please answer the questions by circling the appropriate number or by filling in the answer as requested.
  4. Several items in the survey ask about the effects of kidney disease on your life. Some items will ask about limitations related to your kidney disease, and some items will ask about your well-being. Some questions may look like others, but each one is different. Please answer every question as honesty as possible. If you are unsure about how to answer a question, please give the best answer you can. this will allow us to have an accurate picture of the different experiences of individuals with kidney disease.

THANK YOU FOR COMPLETING THIS SURVEY

Please note that this form will NOT be stored online in anyway. No personal information about you can be accepted. This form is provided for informational purposes only.

YOUR HEALTH
1. In general, would you say your health is:
Unchecked Excellent Very good Good Fair Poor
SF1___
2. Compared to one year ago, how your you rate your health in general now?
  • Unchecked
  • Much better now than one year ago
  • Somewhat better now than one year ago
  • About the same as one year ago
  • Somewhat worse than one year ago
  • Much worse now than one year ago
SF2___
3. The following items are about activities you might do during a typical day. Does you health now limit you in these activities? If so, how much?
  • Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports
    Unchecked yes, limited a Lot yes, limited a little No, not limited at all
  • Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf
    Unchecked yes, limited a Lot yes, limited a little No, not limited at all

  • Lifting or carrying groceries
    Unchecked yes, limited a Lot yes, limited a little No, not limited at all

  • Climbing several flights of stairs
    Unchecked yes, limited a Lot yes, limited a little No, not limited at all

  • Climbingone flights of stairs
    Unchecked yes, limited a Lot yes, limited a little No, not limited at all

  • Bending, kneeling or stooping
    Unchecked yes, limited a Lot yes, limited a little No, not limited at all

  • Walking more than a mile,
    Unchecked yes, limited a Lot yes, limited a little No, not limited at all

  • Walking several blocks
    Unchecked yes, limited a Lot yes, limited a little No, not limited at all

  • Walking one block
    Unchecked yes, limited a Lot yes, limited a little No, not limited at all

  • Bathing or dressing yourself
    Unchecked yes, limited a Lot yes, limited a little No, not limited at all

SF3A___
SF3B___
SF3C___
SF3D___
SF3E___
SF3F___
SF3G___
SF3H___
SF3I___
SF3J___
4. During the past four weeks, have you had any of the following problems with your work or other regular activities as a result of your physical health?
  • Cut down the amount of time you spend on work on other activities?
    Unchecked Yes No
  • Accomplished less than you would have liked?
    Unchecked Yes No
  • Were limited in the kind of work or other activites?
    Unchecked Yes No
  • Had difficultyperforming the work or other activities (for example, it took extra effort)?
    Unchecked Yes No
SF4A___
SF4B___
SF4C___
SF4D___
5. During the past four weeks,have you had any of the following problems with your work or other regular daily activities as a result of any emotion problems(such as feeling depressed or anxious)?
  • Cut down the amount of time you spend on work on other activities?

  • Unchecked Yes No
  • Accomplished less than you would have liked?

  • Unchecked Yes No
  • Didn't do work or other activities kind as carefully as usual?

  • Unchecked Yes No
SF5A___
SF5B___
SF5C___
6. During the past four weeks,to whatextent have yourphysical health or emotion problemsinterfered with your normal social activities with family, friends, neighbors, or groups?
Unchecked Not at all Slightly Moderately Quite a bit Extremely
SF6___
7. How much bodilypain have you had during the past four weeks?
Unchecked None Very mild Mild Moderate Severe Very severe
SF7___
8. During the past four weeks,how much did pain interfere with your normal work (including work outside the home and housework)?
Unchecked Not at all Slightly Moderately Quite a bit Extremely
SF8___
9. These questions are about how you feel and how things have been with you during the past 4 weeks. For each quesiton, please give the one answer that comes closese to the way you have been feeling.

How much of the time during the past 4 weeks
  • Did you feel full of pep?

  • Unchecked 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?

  • Unchecked 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?

  • Unchecked 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 and peaceful?

  • Unchecked 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 a lot of energy?

  • Unchecked 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?

  • Unchecked 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 worn out?

  • Unchecked 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 happy person?

  • Unchecked 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 tired

  • Unchecked 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
SF9A___
SF9B___
SF9C___
SF9D___
SF9E___
SF9F___
SF9G___
SF9H___
SF9I___
10. During past 4 weeks, how much of the time have your physical health or emotional problems interfered with your social activities?
Unchecked All of the time Most of the time Some of the time A little of the time None of the time
SF10___
11. Please choose the answer that best describes how TRUE or FALSE each of the following statements is for you.
  • I seem to get sick a little easier than other people

  • Unchecked Definitely True Mostly True Don't Know Mostly False Always False
  • I am as healthy as anybody I know

  • Unchecked Definitely True Mostly True Don't Know Mostly False Always False
  • I expect my health to get worse

  • Unchecked Definitely True Mostly True Don't Know Mostly False Always False
  • My health is excellent

  • Unchecked Definitely True Mostly True Don't Know Mostly False Always False

YOUR KIDNEY DISEASE
SF11A___
SF11B___
SF11C___
SF11D___
12. How TRUE or FALSE is eachof the following statements for you?
  • My kidney disease interferes too much with my life

  • Unchecked Definitely True Mostly True Don't Know Mostly False Always False
  • Too much time is spent dealing with my kidney disease

  • Unchecked Definitely True Mostly True Don't Know Mostly False Always False
  • I feel frustrated dealing with my kidney disease

  • Unchecked Definitely True Mostly True Don't Know Mostly False Always False
  • I feel like a burden on my family

  • Unchecked Definitely True Mostly True Don't Know Mostly False Always False
SF12A___
SF12B___
SF12C___
SF12D___
13. These questions are about how you feel and how things have ben going during the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling? How much of the time during the past 4 weeks
    Unchecked None of the Time A Little of the Time Some of the Time A Good bit of the Time Most of the Time All of the Time
  • Did you react slowly to things that were said or done?

  • Unchecked None of the Time A Little of the Time Some of the Time A Good bit of the Time Most of the Time All of the Time
  • Did you act irritable toward those around you?

  • Unchecked None of the Time A Little of the Time Some of the Time A Good bit of the Time Most of the Time All of the Time
  • Did you have difficulty concentrating or thinking?


  • Unchecked None of the Time A Little of the Time Some of the Time A Good bit of the Time Most of the Time All of the Time
  • Did you get along well with other people?

  • Unchecked None of the Time A Little of the Time Some of the Time A Good bit of the Time Most of the Time All of the Time
  • Did you become confused?

  • Unchecked None of the Time A Little of the Time Some of the Time A Good bit of the Time Most of the Time All of the Time
SF13A___
SF13B___
SF13C___
SF13D___
SF13E___
SF13F___
14. During the past 4 weeks, to what extent were you bothered by each of the following?
  • Soreness in your muscles?

  • Unchecked Not at all bothered Somewhat bothered Moderately bothered Very Much Bothered Extremely Bothered
  • Chest pain?

  • Unchecked Not at all bothered Somewhat bothered Moderately bothered Very Much Bothered Extremely Bothered
  • Cramps?

  • Unchecked Not at all bothered Somewhat bothered Moderately bothered Very Much Bothered Extremely Bothered
  • Itchy skin?

  • Unchecked Not at all bothered Somewhat bothered Moderately bothered Very Much Bothered Extremely Bothered
  • Dry skin?

  • Unchecked Not at all bothered Somewhat bothered Moderately bothered Very Much Bothered Extremely Bothered
  • Shortness of breath?

  • Unchecked Not at all bothered Somewhat bothered Moderately bothered Very Much Bothered Extremely Bothered
  • Faintness or dizziness?

  • Unchecked Not at all bothered Somewhat bothered Moderately bothered Very Much Bothered Extremely Bothered
  • Lack of appetite?

  • Unchecked Not at all bothered Somewhat bothered Moderately bothered Very Much Bothered Extremely Bothered
  • Washed out or drained?

  • Unchecked Not at all bothered Somewhat bothered Moderately bothered Very Much Bothered Extremely Bothered
  • Numbness in hands or feet?

  • Unchecked Not at all bothered Somewhat bothered Moderately bothered Very Much Bothered Extremely Bothered
  • Nausea or upset stomach?

  • Unchecked Not at all bothered Somewhat bothered Moderately bothered Very Much Bothered Extremely Bothered
  • Problems with your access site (hemo only)?

  • Unchecked Not at all bothered Somewhat bothered Moderately bothered Very Much Bothered Extremely Bothered
  • Problems with your cathether site (peritoneal only)?

  • Unchecked Not at all bothered Somewhat bothered Moderately bothered Very Much Bothered Extremely Bothered

EFFECTS OF KIDNEY DISEASE ON YOUR DAILY LIFE
SF14A___
SF14B___
SF14C___
SF14D___
SF14E___
SF14F___
SF14G___
SF14H___
SF14I___
SF14J___
SF14K___
SF14L/M___
15. Some people are bothered by the effects of kidney disease on their daily life, while others are not. How much does kidney disease bother you in each of the following areas?
  • Fluid restrictions?

  • Unchecked Not at all bothered Somewhat bothered Moderately bothered Very Much Bothered Extremely Bothered
  • Dietary restrictions?

  • Unchecked Not at all bothered Somewhat bothered Moderately bothered Very Much Bothered Extremely Bothered
  • Your ability to work around the house?

  • Unchecked Not at all bothered Somewhat bothered Moderately bothered Very Much Bothered Extremely Bothered
  • Your ability to travel?

  • Unchecked Not at all bothered Somewhat bothered Moderately bothered Very Much Bothered Extremely Bothered
  • Being dependent on doctors and other medical staff?

  • Unchecked Not at all bothered Somewhat bothered Moderately bothered Very Much Bothered Extremely Bothered
  • Stress or worries caused by kidney disease?

  • Unchecked Not at all bothered Somewhat bothered Moderately bothered Very Much Bothered Extremely Bothered
  • Your sex life?

  • Unchecked Not at all bothered Somewhat bothered Moderately bothered Very Much Bothered Extremely Bothered
  • Your personal appearance?

  • Unchecked Not at all bothered Somewhat bothered Moderately bothered Very Much Bothered Extremely Bothered
The next three questions are personal and relate to your sexual activity, but your answers are important in understanding how kidney disease impacts on people's lives.
SF15A___
SF15B___
SF15C___
SF15D___
SF15E___
SF15F___
SF15G___
SF15H___
16. Have you had sexual activity in the past 4 weeks? (If "No" Please skip to Question 17)
Unchecked Yes No
  • Enjoyng sex?

  • Unchecked Not a Problem A Little Problem Somewhat of a Problem Very Much a Problem Severe Problem
  • Becoming sexually aroused?

  • Unchecked Not a Problem A Little Problem Somewhat of a Problem Very Much a Problem Severe Problem
SF16___
SF16A___
SF16B___
For the following question, pleas rate your sleep using a scale ranging from 0 representing "very bad" to 10 representing "very good".

If you think your sleep is half-way between "very bad" and "very good," please circle 5. If you think your sleep is one level better than 5, circle 6. If you think your sleep is one level worse than 5, circle 4 (and so on)

17. On a scale from 0to10, how would you rate your sleep overall?

Unchecked Very Bad 0 1 2 3 4 5 6 7 8 9 Very Good 10
SF17___
18. How often during the past 4 weeks did you
  • Awaken during the night and have trouble falling asleep again?

  • Unchecked None of the Time A Little of the Time Some of the Time A Good bit of the Time Most of the Time All of the Time
  • Get the amount of sleep you need?

  • Unchecked None of the Time A Little of the Time Some of the Time A Good bit of the Time Most of the Time All of the Time
  • Have trouble staying awake during the day?

  • Unchecked None of the Time A Little of the Time Some of the Time A Good bit of the Time Most of the Time All of the Time


SF18A___
SF18B___
SF18C___

19. Concerning your family and friends, how satisfied are you with
  • the amount of time you are able to spend with your family and friends?
    Unchecked Very dissatisfied Somewhat dissatisfied Somewhat satisfied Very satisfied
  • The support you receive from your family and friends?
    Unchecked Very dissatisfied Somewhat dissatisfied Somewhat satisfied Very satisfied
SF19A___
SF19B___
20. During the past 4 weeks, did you work at a paying job?
Unchecked Yes No
SF20___
21. Does your health keep you from working at a paying job?
Unchecked Yes No

22. Overall, how would you rate your health?
SF21___
Worst possible (as bad or worse than being dead) Unchecked 1 2 3 4 5 Half-way between worst and best 6 7 8 9 Best possible health 10
SATISFACTION WITH CARE
SF22___
23. Think about the care you receive for kidney dialysis. In terms of your satisfaction, how would you rate the friendliness and interest shown in you as a person? Unchecked Very Poor Poor Fair Good Very Good Excellent The Best SF23___
24. How TRUE or FALSE is each of the following statements?
  • Dialysis staff encourage me to be as independent as possible

  • Unchecked Definitely True Mostly True Don't Know Mostly False Definitely False
  • Dialysis staff support me in coping with my kidney disease

  • Definitely True Unchecked Mostly True Don't Know Mostly False Definitely False
BACKGROUND INFORMATION
SF24A___
SF24B___
25. Do you currently take prescription medications regularly (4 or more days a week) that are prescribed by your doctor for a medical condition? Please don't count over the counter medications like antacids or aspirin.If "No" please skip to Question 26.
No Yes

25a. How many different prescription medications do you currently take? Number of Medications:
q25___
q25a___
26.How many days total in the last 6 months did you stay in any hospital overnight or longer?(if none, please write in 0)days
q26___
27. How many days total in the last 6 months did you receive care at a hospital, but came home the same day? (if none, please write in 0)days
q27___
28.What caused your kidney disease?
Don't know Hypertension (High Blood Pressure) Diabetes Polycystic Kidney Disease Chronic Glomerulonephritis Chronic Pyelonephritis Other (please specify)
q28___
29.When were you born? Year (four digits)

q29___
30. What is the highest level of school you have completed?
8th grade or less Some high school or less High school diploma or GED Vocational school or some college College degree Professional or graduate degree
q30___
31.What is your gender?
Male Female
q31___
32.How do ou describe yourself?
Asian American or Black Hispanic or Latino Native American or American Indian Asian or Pacific Islander White Other (please specify)
S32___
33.Are you currently married
No Yes
S33___
34.During the last 30 days, were you:
1. Working full-time 2. Working part-time 3. Unemployed, laid off, or looking for work 4. Retired 5. Disabled 6. In School 7. Keeping house 8. None of the above
q34___
35.What kind of health insurance do you have? q35___
36.What was you total household income (from all sources) before taxes in the LAST CALENDAR YEAR, including yourself, your partner, and others you regard as family who live in your household? (Please remember your answers are confidential) q36___
37.Did someone help you fill out this survey?
YESNO

q37___
38. What is today's date?

THANK YOU. YOU HAVE COMPLETED THE SURVEY

q38___

© 2008-12, Stephen Z. Fadem, M.D., FACP, FASN. All rights reserved. No part of this application may be duplicated without written permission from the author.

DISCLAIMER: The licensee or user understand and agree that the technology and content of this application are provided for educational purposes only. All calculations must be checked for accuracy and confirmed before use, clinical or otherwise. All medical decisions must be based upon the clinical judgment of a licensed physician. Licensee or user assumes the duty to have any and all laboratory values or calculations verified by a licensed physician. Neither licensor nor its associated authors or other entities warrant the accuracy of any information provided by or resulting from the technology or the content for clinical management, and licensee or user agree that no such persons or entities shall be liable for any adverse consequences resulting from the use of any of the same.

Licensee or user shall indemnify, defend and hold harmless licensor, its affiliates, and their respective officers, directors, owners, agents, information providers and employees from and against any claims, demands or causes of action whatsoever, including without limitation those arising on account of, or resulting from the exercise or practice of the license granted hereunder by licensee, its sublicensees, if any, its subsidiaries or other officers, employees, agents or representatives.