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["Quality of Life Assessment Tool – Open Future Health "]
[]
["This survey asks about your health and daily activities. Answer every question by putting the appropriate number in the yellow box."]
["Your answers are entirely between you and your computer unless you choose to share them with your spouse your family or your doctor."]
["The answers assuming perfect health are included and need not be changed.  Downgrade as necessary. You can use any number 0 to 100."]
["If you are unsure how to answer a question please give the best answer you can.  You can use a number between scores if you like. "]
["There are 54 questions. The score is tallied for you and a report is available at the end.  It will take about 20 minutes to complete."]
[]
["QUESTION ",1]
["In general how is your health."]
["Excellent","Very Good","Good","Fair","Poor"]
[100,75,50,25,0,null,100]
[]
["QUESTION ",2]
["Compared with a year ago, how would you rate your health now?"]
["Much Better","Better","The Same","A little worse","Much Worse"]
[100,75,50,25,0,null,100]
[]
["The following questions are about your typical day."]
["How much does your health LIMIT your activities"]
["QUESTION ",3]
["Vigorous Activities like running, lifting heavy objects or participating in sports"]
[null,null,"Limited a Lot","Limited","Not Limited"]
[null,null,0,50,100,null,100]
[]
["QUESTION ",4]
["Moderate activities like moving a table, vacuum cleaning, bowing, or playing golf."]
[null,null,"Limited a Lot","Limited","Not Limited"]
[null,null,0,50,100,null,100]
[]
["QUESTION ",5]
["Lifting and carrying groceries"]
[null,null,"Limited a Lot","Limited","Not Limited"]
[null,null,0,50,100,null,100]
[]
["QUESTION ",6]
["Climbing three flights of stairs"]
[null,null,"Limited a Lot","Limited","Not Limited"]
[null,null,0,50,100,null,100]
[]
["QUESTION ",7]
["Climbing one flight of stairs"]
[null,null,"Limited a Lot","Limited","Not Limited"]
[null,null,0,50,100,null,100]
[]
["QUESTION ",8]
["Bending kneeling and stooping. Getting up and down."]
[null,null,"Limited a Lot","Limited","Not Limited"]
[null,null,0,50,100,null,100]
[]
["QUESTION ",9]
["Walking MORE than a three killometers"]
[null,null,"Limited a Lot","Limited","Not Limited"]
[null,null,0,50,100,null,100]
[]
["QUESTION ",10]
["Walking ONE killometer"]
[null,null,"Limited a Lot","Limited","Not Limited"]
[null,null,0,50,100,null,100]
[]
["QUESTION ",11]
["Walking One city block."]
[null,null,"Limited a Lot","Limited","Not Limited"]
[null,null,0,50,100,null,100]
[]
["QUESTION ",12]
["Getting up, bathing and dressing yourself. "]
[null,null,"Limited a Lot","Limited","Not Limited"]
[null,null,0,50,100,null,100]
[]
["During the LAST FOUR WEEKS have you had the following problems"]
["As a result of your Physical Health "]
[]
["QUESTION ",13]
["Cut down on the amount of time you could spend on work or activities."]
[null,null,null,"Yes","No"]
[null,null,null,0,100,null,100]
[]
["QUESTION ",14]
["Accomplished less than you would expect and like to do."]
[null,null,null,"Yes","No"]
[null,null,null,0,100,null,100]
[]
["QUESTION ",15]
["Limited in the kind of work you could do."]
[null,null,null,"Yes","No"]
[null,null,null,0,100,null,100]
[]
["QUESTION ",16]
["Had difficulty performing the work or other activities you are doing."]
[null,null,null,"Yes","No"]
[null,null,null,0,100,null,100]
[]
["During the LAST FOUR WEEKS have you had the following problems"]
["As a result of your Emotional Problems (Like being depressed or anxious)"]
[]
["QUESTION ",17]
["Cut down on the amount of time you could spend on work or activities."]
[null,null,null,"Yes","No"]
[null,null,null,0,100,null,100]
[]
["QUESTION ",18]
["Accomplished less than you would expect and like to do."]
[null,null,null,"Yes","No"]
[null,null,null,0,100,null,100]
[]
["QUESTION ",19]
["Didn’t do the work or other activities as carefully as you usually do."]
[null,null,null,"Yes","No"]
[null,null,null,0,100,null,100]
[]
["During the LAST FOUR WEEKS have you had the following problems"]
[]
["QUESTION ",20]
["To what extent has your Physical Health OR Emotional Problems restricted Social Activities"]
["particularly in clubs, groups, or with family and friends. "]
["Not at all","Very Mild","Moderately","Quite a bit","Extremely"]
[100,75,50,25,0,null,100]
[]
["QUESTION ",21]
["How much bodily PAIN have you suffered in the last FOUR WEEKS"]
["None","Slightly","Mild","Moderate","Severe","Very Severe"]
[100,80,60,40,20,0,100]
[]
["QUESTION ",22]
["How much did PAIN interfere with your normal work at home or elsewhere in the last FOUR WEEKS"]
["Not at all","A little bit","Moderately","Quite a bit","Extremely"]
[100,75,50,25,0,null,100]
[]
["During the LAST FOUR WEEKS how have you been feeling?"]
["Give one answer for each line on how you have bee feeling."]
[]
["QUESTION ",23]
["Did you feel full of energy?"]
["All of the time","Most of the time","More than ","Less than","A little of","None of the time"]
[null,null,"half the time","half the time"," the time"]
[100,80,60,40,20,0,100]
[]
["QUESTION ",24]
["Have you been a very nervous person?"]
["All of the time","Most of the time","More than ","Less than","A little of","None of the time"]
[null,null,"half the time","half the time"," the time"]
[0,20,40,60,80,100,100]
[]
["QUESTION ",25]
["Have you felt so down in the dumps that nothing can cheer you up?"]
["All of the time","Most of the time","More than ","Less than","A little of","None of the time"]
[null,null,"half the time","half the time"," the time"]
[0,20,40,60,80,100,100]
[]
[]
["QUESTION ",26]
["Have you felt calm and peaceful?"]
["All of the time","Most of the time","More than ","Less than","A little of","None of the time"]
[null,null,"half the time","half the time"," the time"]
[100,80,60,40,20,0,100]
[]
["QUESTION ",27]
["Did you have a lot of energy?"]
["All of the time","Most of the time","More than ","Less than","A little of","None of the time"]
[null,null,"half the time","half the time"," the time"]
[100,80,60,40,20,0,100]
[]
["QUESTION ",28]
["Have you felt downhearted and blue?"]
["All of the time","Most of the time","More than ","Less than","A little of","None of the time"]
[null,null,"half the time","half the time"," the time"]
[0,20,40,60,80,100,100]
[]
["QUESTION ",29]
["Did you feel worn out?"]
["All of the time","Most of the time","More than ","Less than","A little of","None of the time"]
[null,null,"half the time","half the time"," the time"]
[0,20,40,60,80,100,100]
[]
["QUESTION ",30]
["Have you been happy as a person?"]
["All of the time","Most of the time","More than ","Less than","A little of","None of the time"]
[null,null,"half the time","half the time"," the time"]
[100,80,60,40,20,0,100]
[]
["QUESTION ",31]
["Did you feel tired?"]
["All of the time","Most of the time","More than ","Less than","A little of","None of the time"]
[null,null,"half the time","half the time"," the time"]
[0,20,40,60,80,100,100]
[]
["QUESTION ",32]
["Did you feel rested on waking in the morning?"]
["All of the time","Most of the time","More than ","Less than","A little of","None of the time"]
[null,null,"half the time","half the time"," the time"]
[100,80,60,40,20,0,100]
[]
["QUESTION ",33]
["How much of the TIME has your Physical Health OR Emotional Problems restricted Social Activities"]
["particularly in clubs, groups, or with family and friends. "]
["All of the time","Most of the time","Sometimes","A little of ","None of the time"]
[null,null,null,"the time"]
[0,25,50,75,100,null,100]
[]
["How True of False are each of the following statements for you?"]
["QUESTION ",34]
["I seem to get sick easier than other people."]
["Definitely true","Mostly True","Not Sure","Mostly False","Definitely False"]
[0,25,50,75,100,null,100]
[]
["QUESTION ",35]
["I’m as healthy as anyone I know, who’s close to my age."]
["Definitely true","Mostly True","Not Sure","Mostly False","Definitely False"]
[100,75,50,25,0,null,100]
[]
["QUESTION ",36]
["I expect my health to get worse in the next year."]
["Definitely true","Mostly True","Not Sure","Mostly False","Definitely False"]
[0,25,50,75,100,null,100]
[]
["QUESTION ",37]
["My health is Excellent. I use one or fewer medications."]
["Definitely true","Mostly True","Not Sure","Mostly False","Definitely False"]
[100,75,50,25,0,null,100]
[]
["How much TIME in the last FOUR WEEKS ?"]
["QUESTION ",38]
["Were you discouraged by your health problems?"]
["All of the time","Most of the time","More than ","Less than","A little of","None of the time"]
[null,null,"half the time","half the time"," the time"]
[0,20,40,60,80,100,100]
[]
["QUESTION ",39]
["Were you frustrated by your health?"]
["All of the time","Most of the time","More than ","Less than","A little of","None of the time"]
[null,null,"half the time","half the time"," the time"]
[0,20,40,60,80,100,100]
[]
["QUESTION ",40]
["Was your health a worry in your life?"]
["All of the time","Most of the time","More than ","Less than","A little of","None of the time"]
[null,null,"half the time","half the time"," the time"]
[0,20,40,60,80,100,100]
[]
["QUESTION ",41]
["Did you feel weighed down by your health problems?"]
["All of the time","Most of the time","More than ","Less than","A little of","None of the time"]
[null,null,"half the time","half the time"," the time"]
[0,20,40,60,80,100,100]
[]
["QUESTION ",42]
["Have you had problems concentrating and thinking?"]
["All of the time","Most of the time","More than ","Less than","A little of","None of the time"]
[0,null,"half the time","half the time"," the time"]
[null,20,40,60,80,100,100]
[]
["QUESTION ",43]
["Have you had problems keeping your attention on an activity for long? "]
["All of the time","Most of the time","More than ","Less than","A little of","None of the time"]
[null,null,"half the time","half the time"," the time"]
[0,20,40,60,80,100,100]
[]
["QUESTION ",44]
["Have you had problems with you memory?"]
["All of the time","Most of the time","More than ","Less than","A little of","None of the time"]
[null,null,"half the time","half the time"," the time"]
[0,20,40,60,80,100,100]
[]
["QUESTION ",45]
["Have other people noticed that you are having trouble with your memory or your concentration? "]
["All of the time","Most of the time","More than ","Less than","A little of","None of the time"]
[null,null,"half the time","half the time"," the time"]
[0,20,40,60,80,100,100]
[]
["The next section is about your sexual function and sexual satisfaction . "]
["Give one answer as best you can regarding the LAST FOUR WEEKS. "]
[]
["QUESTION ",46]
["Lack of Sexual Interest"]
["Not a Problem","A Minor ","Sometimes ","Very Much "]
[null,"Problem","a Problem","a Problem"]
[100,66.6,33.3,0,null,null,100]
[]
["QUESTION ",47,"MEN"]
["Difficulty getting and/or keeping an erection"]
["Not a Problem","A Minor ","Sometimes ","Very Much "]
[null,"Problem","a Problem","a Problem"]
[100,66.6,33.3,0,null,"Men Only",100]
[]
["QUESTION ",47,"WOMEN",null,null,"One"]
["Inadequate lubrication. ",null,null,null,null,"or"]
["Not a Problem","A Minor ","Sometimes ","Very Much ",null,"The Other"]
[null,"Problem","a Problem","a Problem"]
[100,66.6,33.3,0,null,"Women Only",0]
[]
["QUESTION ",48]
["Difficulty having an orgasm."]
["Not a Problem","A Minor ","Sometimes ","Very Much "]
[null,"Problem","a Problem","a Problem"]
[100,66.6,33.3,0,null,null,100]
[]
["QUESTION ",49]
["Ability to satisfy a sexual partner."]
["Not a Problem","A Minor ","Sometimes ","Very Much "]
[null,"Problem","a Problem","a Problem"]
[100,66.6,33.3,0,null,null,100]
[]
["QUESTION ",50]
["Overall how satisfied were you with you sexual function in the last four weeks?"]
["Very Satisfied","Mostly Satisfied","Not Sure","Dissatisfied","Very Dissatisfied"]
[100,75,50,25,0,null,100]
[]
["QUESTION ",51]
["In the last four weeks how much has your bowel or bladder function interfered with you normal social activities?"]
["Not at all","Slightly","Moderately","Quite a bit","Extremely"]
[100,75,50,25,0,null,100]
[]
["QUESTION ",52]
["In the last four weeks how much has pain interfered with your enjoyment of life?"]
["Not at all","Slightly","Moderately","Quite a bit","Extremely"]
[100,75,50,25,0,null,100]
[]
["QUESTION ",53]
["On a scale of 1 to 100 how do you rate your quality of life? 100 is Best Possible. 0 is worst possible."]
["Excellent","Very Good","It’s OK","Pretty Poor","Terrible"]
[100,75,50,25,0,null,100]
[]
["QUESTION ",54]
["How do you feel about your life as a whole? "]
["Delighted","Pleased","Mostly Happy","Dissatisfied","Unhappy","Terrible"]
[100,85,65,50,30,10,100]
[]
[]
["Quality of Life Assessment Tool – Weighted Assessment Tool"]
[null,null,null,"Percentage ",null,"Physical Function"]
[null,null,null,"Score",null,"Weighted"]
["Physical health",null,null,{"$f":"(G322+G24+G29+G34+G39+G44+G49+G54+G59+G64+G69)/11","v":100},null,{"$f":"D333*0.17","v":17}]
[]
["Role Limitations because of physical health",null,null,{"$f":"(+G77+G82+G87+G92)/4","v":100},null,{"$f":"+D335*0.12","v":12}]
[]
["Pain",null,null,{"$f":"(+G123+G128+G317)/3","v":100},null,{"$f":"+D337*0.11","v":11}]
[]
["Energy",null,null,{"$f":"(+G137+G162+G174+G186+G192)/5","v":100},null,{"$f":"+D339*0.12","v":12}]
[]
["Health Perceptions",null,null,{"$f":"(+G12+G205+G210+G215+G220)/5","v":100},null,{"$f":"D341*0.17","v":17}]
[]
["Social Function",null,null,{"$f":"(+G118+G199+G312)/3","v":100},null,{"$f":"+D343*0.12","v":12}]
[]
["Health Distress",null,null,{"$f":"(+G227+G233+G239+G245)/4","v":100},null,{"$f":"+D345*0.11","v":11}]
[]
["Sexual Function",null,null,{"$f":"(+G278+G284+G290+G296+G302)/4","v":100},null,{"$f":"+D347*0.08","v":8}]
[]
[null,null,null,"Composite Physical Health Score",null,{"$f":"+SUM(F333:F347)/100","v":1}]
[]
[null,null,null,null,null,"Mental Health"]
[null,null,null,null,null,"Weighted"]
["Cognitive Function",null,null,{"$f":"(+G263+G269+G251+G257)/4","v":100},null,{"$f":"+D353*0.15","v":15}]
[]
["Role Limitations because of emotional problems",null,null,{"$f":"(+G100+G105+G110)/3","v":100},null,{"$f":"+D355*0.24","v":24}]
[]
["Emotional Well-being",null,null,{"$f":"(+G180+G168+G156+G149+G143)/5","v":100},null,{"$f":"+D357*0.29","v":29}]
[]
["Health Distress",null,null,{"$f":"(+G227+G233+G239+G245)/4","v":100},null,{"$f":"+D359*0.14","v":14}]
[]
["Overall Quality of life. ",null,null,{"$f":"(+G322+G327)/2","v":100},null,{"$f":"+D361*0.18","v":18}]
[]
[null,null,null,"Composite Mental Health Score",null,{"$f":"+SUM(F353:F361)/100","v":1}]
[]
["Satisfaction with Sexual Function",null,null,{"$f":"(+D347+G307)/2","v":100},null,{"$f":"+D365/100","v":1}]