Patient Reported Outcomes Assessment
KDQOL 35 Symptom List
What is the purpose of the study?
This part of the study is being carried out in cooperation with physicians and their
patients. The purpose is to assess the quality of life and symptoms of patients with
autonomous hyperparathyroidism.
What will I be asked to do?
For this study, we want you to complete a survey today about your health and how you
feel. Please put an “X” in the box next to your answer to each question.
Confidentiality of information?
We do not ask for your name. Your answers will be combined with those of other
participants in reporting the findings of the study. Any information that would permit
identification of you will be regarded as strictly confidential.
How will participation benefit me?
The information you provide will tell us 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 to patients with autonomous
hyperparathyroidism.
Thank you for completing this survey!
These questions are about how much you were bothered by certain
conditions during the past 4 weeks. For each question, please give the
one answer that comes closest to the way you have been feeling.
1. During the past 4 weeks, to what extent were you bothered by each
of the following? [Mark one box on each line]
Not at all Somewhat Moderately
bothered bothered bothered
Very
Extremely
much
bothered
bothered
A
Dry skin? ..............................
1
2
3
4
5
B
Itchy skin? ............................
1
2
3
4
5
C
Lack of strength? .................
1
2
3
4
5
D
Fatigue, weakness? ..............
1
2
3
4
5
E
Washed out or drained? .......
1
2
3
4
5
F
Muscle soreness? .................
1
2
3
4
5
G
Excessive thirst? ..................
1
2
3
4
5
H
Dry mouth?...........................
1
2
3
4
5
I
Joint pain? ............................
1
2
3
4
5
J
Trouble sleeping? .................
1
2
3
4
5
K
Easy bruising? ......................
1
2
3
4
5
L
Sleepiness during day? ........
1
2
3
4
5
M
Cramps during dialysis?.......
1
2
3
4
5
N
Joint stiffness?......................
1
2
3
4
5
O
High blood pressure? ...........
1
2
3
4
5
P
Back pain? ............................
1
2
3
4
5
KDQOL-35-Symptom List - United States/English - Mapi Research Institute.
f:\institut\cultadap\project\5356\study5356\questionnaire\original\forproject\kdqol-35-symptom list_ts1.0_eng-usori-for vf.doc-05/08/09-az
Not at all Somewhat Moderately
bothered bothered bothered
Very
Extremely
much
bothered
bothered
Numbness in hands or
feet? ......................................
1
2
3
4
5
R
Bone aches? .........................
1
2
3
4
5
S
Muscle spasms? ...................
1
2
3
4
5
T
Lack of appetite? ..................
1
2
3
4
5
U
Headaches?...........................
1
2
3
4
5
V
Nausea or upset
stomach? ...............................
1
2
3
4
5
W
Low blood pressure? ............
1
2
3
4
5
X
Trouble with memory? .........
1
2
3
4
5
Y
Shortness of breath? .............
1
2
3
4
5
Z
Cramps after dialysis? ..........
1
2
3
4
5
AA
Faintness or dizziness? ........
1
2
3
4
5
BB
Hot or cold spells? ...............
1
2
3
4
5
CC
Trouble concentrating? ........
1
2
3
4
5
DD
Trouble getting breath? ........
1
2
3
4
5
EE
Blurred vision? .....................
1
2
3
4
5
FF
Chest pain? ...........................
1
2
3
4
5
GG
Swelling of ankles? ..............
1
2
3
4
5
HH
Loss of taste?........................
1
2
3
4
5
II
Clotting or other access
site problems? ......................
1
2
3
4
5
Q
KDQOL-35-Symptom List - United States/English - Mapi Research Institute.
f:\institut\cultadap\project\5356\study5356\questionnaire\original\forproject\kdqol-35-symptom list_ts1.0_eng-usori-for vf.doc-05/08/09-az