Your Health and Well-Being
Kidney Disease and Quality of Life (KDQOLTM-36)

Programmed by Stephen Z. Fadem, M.D., FACP, FASN

This survey asks for your views about your health. This information will demonstrate how you feel and how well you are able to do your usual activities.

These questions are from Kidney Disease and Quality of LifeTM(KDQOLTM-36) English Version 1. Copyright © 2000 by RAND and the University of Arizona Study of Quality of Life For Patients on Dialysis. This site is posted for education purposes only. For more information contact the KDQOL WORKING GROUP WEBSITE.

What is the purpose of the KDQOL?

The purpose is to assess the quality of life of patients with kidney disease.

What will I be asked to do?

Complete the questions below about your health, how you feel and your background.

Confidentiality of information?

No information is being recorded or stored. This is purely for your benefit to understand the concepts this test is based on. There are several other resources like KDQOL COMPLETE by the Medical Education Institute that can record and analyze scores in conjustion with your dialysis facility.

How will participation benefit me?

The information you provide will demonstrate how you feel about your care and further understanding about the effects of medical care on the health of patients. This information will help to evaluate the care delivered. This survey includes a wide variety of questions about your health and your life. It will show how you feel about each of these issues.


Your Health

1. In general, would you say your health is: [Check the one box that best describes your answer.]

Excellent Very good Good Fair Poor

The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much? [Check the box on each line.]

YES,
limited a lot		YES,
limited a little		NO,
not limited at all
2. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf
3. Climbing several flights of stairs

During the past 4 weeks, have you had any of the following problems with your work
or other regular daily activities as a result of your physical health?

YESNO
4. Accomplished less than you would like
5. Were limited in the kind of work or other activities

During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of any
emotional problems (such as feeling depressed or anxious)?

YESNO
6. Accomplished less than you would like
7. Did not do work or other activities as carefully as usual
8. During the past 4 weeks,how much did pain interfer ewith your normal work (including both work outside the home and housework)?
Not at all A little bit Moderately Quite a bit Extremely

These questions are about how you feel and how things have been with you 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

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
9. Have you felt calm and peaceful?
10. Did you have a lot of energy?
11. Have you felt downhearted and blue?
12. 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 Some
of the time A little
of the timeNone
of the time

Your Kidney Disease

How true or false is each of the following statements for you?

Definitely
trueMostly
trueDo not
knowMostly
falseDefinitely
false 13. My kidney disease interferes too much with my life 14. Too much of my time is spent dealing with my kidney disease 15. I feel frustrated dealing with my kidney disease 16. I feel like a burden on my family

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

Not at all
botheredSomewhat
botheredModerately
botheredVery much
botheredExtremely
bothered 17. Soreness in your muscles? 18. Chest pain? 19. Cramps? 20. Itchy skin? 21. Dry skin? 22. Shortness of breath? 23. Faintness or dizziness? 24. Lack of appetite? 25. Washed out or drained? 26. Numbness in hands or feet? 27. Nausea or upset stomach? 28a. (Hemodialysis patient only Problems with your access site? 28b. (Peritoneal dialysis patient only) Problems with your catheter site?

Effects of Kidney Disease on Your Daily Life

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?

Not at all
bothered Somewhat
botheredModerately
botheredVery much
bothered Extremely
bothered 29. Fluid restriction? 30. Dietary restriction?. 31. Your ability to work around the house? 32. Your ability to travel? 33. Being dependent on doctors and other medical staff? 34. Stress or worries caused by kidney disease? 35. Your sex life? 36. Your personal appearance?

Thank you for completing these questions!

SCORES

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