Health-Related Quality of Life Scale | SPARQtools

Core Healthy Days Module

1. Would you say that in general your health is:

2. Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?

3. Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?

If you answered “none” to questions 2 and 3, skip question 4 below:

4. During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation?

Activity Limitations Module

Instructions: These next questions are about physical, mental, or emotional problems or limitations you may have in your daily life.

5. Are you LIMITED in any way in any activities because of any impairment or health problem?

If the answer is no, skip to “Healthy Days Symptoms Module.”

6. What is the MAJOR impairment or health problem that limits your activities?

7. For HOW LONG have your activities been limited because of your major impairment or health problem?

8. Because of any impairment or health problem, do you need the help of other persons with your PERSONAL CARE needs, such as eating, bathing, dressing, or getting around the house?

9. Because of any impairment or health problem, do you need the help of other persons in handling your ROUTINE needs, such as everyday household chores, doing necessary business, shopping, or getting around for other purposes?

Healthy Days Symptoms Module

10. During the past 30 days, for about how many days did PAIN make it hard for you to do your usual activities, such as self-care, work, or recreation?

11. During the past 30 days, for about how many days have you felt SAD, BLUE, or DEPRESSED?

12. During the past 30 days, for about how many days have you felt WORRIED, TENSE, or ANXIOUS?

13. During the past 30 days, for about how many days have you felt you did NOT get ENOUGH REST or SLEEP?

14. During the past 30 days, for about how many days have you felt VERY HEALTHY AND FULL OF ENERGY?