The KDQOL-SF^TM 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-SF^TM), 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: Respond here Excellent Very good Good Fair Poor
2. Compared to one year ago, how your you rate your health in general now? Respond here 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
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 Respond here 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 Respond here yes, limited a Lot yes, limited a little No, not limited at all
• Lifting or carrying groceries Respond here yes, limited a Lot yes, limited a little No, not limited at all
• Climbing several flights of stairs Respond here yes, limited a Lot yes, limited a little No, not limited at all
• Climbingone flights of stairs Respond here yes, limited a Lot yes, limited a little No, not limited at all
• Bending, kneeling or stooping Respond here yes, limited a Lot yes, limited a little No, not limited at all
• Walking more than a mile, Respond here yes, limited a Lot yes, limited a little No, not limited at all
• Walking several blocks Respond here yes, limited a Lot yes, limited a little No, not limited at all
• Walking one block Respond here yes, limited a Lot yes, limited a little No, not limited at all
• Bathing or dressing yourself Respond here yes, limited a Lot yes, limited a little No, not limited at all

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? Respond here Yes No
• Accomplished less than you would have liked? Respond here Yes No
• Were limited in the kind of work or other activites? Respond here Yes No
• Had difficultyperforming the work or other activities (for example, it took extra effort)? Respond here Yes No

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?
Respond here Yes No
• Accomplished less than you would have liked?
Respond here Yes No
• Didn't do work or other activities kind as carefully as usual?
Respond here Yes No

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? Respond here Not at all Slightly Moderately Quite a bit Extremely
7. How much bodilypain have you had during the past four weeks? Respond here None Very mild Mild Moderate Severe Very severe
8. During the past four weeks,how much did pain interfere with your normal work (including work outside the home and housework)? Respond here Not at all Slightly Moderately Quite a bit Extremely

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?
Respond here 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?
Respond here 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?
Respond here 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?
Respond here 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?
Respond here 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?
Respond here 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?
Respond here 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?
Respond here 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
Respond here 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

10. During past 4 weeks, how much of the time have your physical health or emotional problems interfered with your social activities? Respond here All of the time Most of the time Some of the time A little of the time None of the time
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
Respond here Definitely True Mostly True Don't Know Mostly False Always False
• I am as healthy as anybody I know
Respond here Definitely True Mostly True Don't Know Mostly False Always False
• I expect my health to get worse
Respond here Definitely True Mostly True Don't Know Mostly False Always False
• My health is excellent
Respond here Definitely True Mostly True Don't Know Mostly False Always False

YOUR KIDNEY DISEASE

12. How TRUE or FALSE is eachof the following statements for you?

• My kidney disease interferes too much with my life
Respond here Definitely True Mostly True Don't Know Mostly False Always False
• Too much time is spent dealing with my kidney disease
Respond here Definitely True Mostly True Don't Know Mostly False Always False
• I feel frustrated dealing with my kidney disease
Respond here Definitely True Mostly True Don't Know Mostly False Always False
• I feel like a burden on my family
Respond here Definitely True Mostly True Don't Know Mostly False Always False

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

• Did you isolate yourself from people around you?
Respond here 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?
Respond here 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?
Respond here 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?
Respond here 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?
Respond here 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?
Respond here 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

14. During the past 4 weeks, to what extent were you bothered by each of the following?

• Soreness in your muscles?
Respond here Not at all bothered Somewhat bothered Moderately bothered Very Much Bothered Extremely Bothered
• Chest pain?
Respond here Not at all bothered Somewhat bothered Moderately bothered Very Much Bothered Extremely Bothered
• Cramps?
Respond here Not at all bothered Somewhat bothered Moderately bothered Very Much Bothered Extremely Bothered
• Itchy skin?
Respond here Not at all bothered Somewhat bothered Moderately bothered Very Much Bothered Extremely Bothered
• Dry skin?
Respond here Not at all bothered Somewhat bothered Moderately bothered Very Much Bothered Extremely Bothered
• Shortness of breath?
Respond here Not at all bothered Somewhat bothered Moderately bothered Very Much Bothered Extremely Bothered
• Faintness or dizziness?
Respond here Not at all bothered Somewhat bothered Moderately bothered Very Much Bothered Extremely Bothered
• Lack of appetite?
Respond here Not at all bothered Somewhat bothered Moderately bothered Very Much Bothered Extremely Bothered
• Washed out or drained?
Respond here Not at all bothered Somewhat bothered Moderately bothered Very Much Bothered Extremely Bothered
• Numbness in hands or feet?
Respond here Not at all bothered Somewhat bothered Moderately bothered Very Much Bothered Extremely Bothered
• Nausea or upset stomach?
Respond here Not at all bothered Somewhat bothered Moderately bothered Very Much Bothered Extremely Bothered
• Problems with your access site (hemo only)?
Respond here Not at all bothered Somewhat bothered Moderately bothered Very Much Bothered Extremely Bothered
• Problems with your cathether site (peritoneal only)?
Respond here Not at all bothered Somewhat bothered Moderately bothered Very Much Bothered Extremely Bothered

EFFECTS OF KIDNEY DISEASE ON YOUR DAILY LIFE

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?
Respond here Not at all bothered Somewhat bothered Moderately bothered Very Much Bothered Extremely Bothered
• Dietary restrictions?
Respond here Not at all bothered Somewhat bothered Moderately bothered Very Much Bothered Extremely Bothered
• Your ability to work around the house?
Respond here Not at all bothered Somewhat bothered Moderately bothered Very Much Bothered Extremely Bothered
• Your ability to travel?
Respond here Not at all bothered Somewhat bothered Moderately bothered Very Much Bothered Extremely Bothered
• Being dependent on doctors and other medical staff?
Respond here Not at all bothered Somewhat bothered Moderately bothered Very Much Bothered Extremely Bothered
• Stress or worries caused by kidney disease?
Respond here Not at all bothered Somewhat bothered Moderately bothered Very Much Bothered Extremely Bothered
• Your sex life?
Respond here Not at all bothered Somewhat bothered Moderately bothered Very Much Bothered Extremely Bothered
• Your personal appearance?
Respond here 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.
16. Have you had sexual activity in the past 4 weeks? (If "No" Please skip to Question 17) Respond here Yes No

• Enjoyng sex?
Respond here Not a Problem A Little Problem Somewhat of a Problem Very Much a Problem Severe Problem
• Becoming sexually aroused?
Respond here Not a Problem A Little Problem Somewhat of a Problem Very Much a Problem Severe Problem

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? Respond here Very Bad 00 1 2 3 4 5 6 7 8 9 Very Good 10
18. How often during the past 4 weeks did you

• Awaken during the night and have trouble falling asleep again?
Respond here 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?
Respond here 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?
Respond here 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

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? Respond here Very dissatisfied Somewhat dissatisfied Somewhat satisfied Very satisfied
• The support you receive from your family and friends? Respond here Very dissatisfied Somewhat dissatisfied Somewhat satisfied Very satisfied

20. During the past 4 weeks, did you work at a paying job? Respond here Yes No
21. Does your health keep you from working at a paying job? Respond here Yes No
22. Overall, how would you rate your health? Respond here Worst possible (as bad or worse than being dead)00 1 2 3 4 5 Half-way between worst and best 6 7 8 9 Best possible health 10

SATISFACTION WITH CARE

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? Respond here Very Poor Poor Fair Good Very Good Excellent The Best
24. How TRUE or FALSE is each of the following statements?

• Dialysis staff encourage me to be as independent as possible
Respond here Definitely True Mostly True Don't Know Mostly False Definitely False
• Dialysis staff support me in coping with my kidney disease
Respond here Definitely True Mostly True Don't Know Mostly False Definitely False

BACKGROUND INFORMATION

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. Respond here No Yes
25a. How many different prescription medications do you currently take? Number of Medications:
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
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
28.What caused your kidney disease? Respond here Don't know Hypertension (High Blood Pressure) Diabetes Polycystic Kidney Disease Chronic Glomerulonephritis Chronic Pyelonephritis Other (please specify)
29.When were you born? Month Day Year
30. What is the highest level of school you have completed? Respond here 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
31.What is your gender? Respond here Male Female
32.How do ou describe yourself? Respond here Asian American or Black Hispanic or Latino Native American or American Indian Asian or Pacific Islander White Other (please specify)
33.Are you currently married Respond here No Yes
34.During the last 30 days, were you: Respond here Working full-time Working part-time Unemployed, laid off, or looking for work Retired Disabled In School Keeping house None of the above
35.What kind of health insurance do you have? select id=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)
37.Did someone help you fill out this survey?
38. What is today's date?
Month Day Year

THANK YOU. YOU HAVE COMPLETED THE SURVEY

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ESRD-targeted Areas ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ __	36-item health survey (SF_36) ___ ___ ___ ___ ___ ___ ___ ___ ___
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