FACT-BR QUALITY OF LIFE SCALE (Version 3.0)

Patient Number:

Patient Initials:

Date:

Below is a list of statements that other people with your illness have said are important. By filling one number per line, please indicate how true each statement has been for you during the past 7 days.

During the past 7 days:

Physical Well Being

	not at all	a little bit	some what	quite a bit	very much
1. I have a lack of energy
2. I have nausea
3. Because of my physical condition, I have trouble meeting the needs of my family
4. I have pain
5. I am bothered by side effects of treatment
6. I feel ill
7. I am forced to spend all my time in bed
8. Looking at the above 7 questions, how much would you say your Physical Well-Being affects your quality of life?

Social/Family Well Being

	not at all	a little bit	some what	quite a bit	very much
9. I feel distant from my friends
10. I get emotional support from my family
11. I get support from my friends and neighbors
12 My family has accepted my illness
13. Family communication about my illness is poor
14. I feel close to my partner (or the person who is my main support)
15. Have you been sexually active during the past year?
NoYes If yes: I am satisfied with my sex life
Looking at the above 7 questions, how much would you say your Social /Family Well-Being affects your quality of life?

During the past 7 days:

Relationship with Doctor

	not at all	a little bit	some what	quite a bit	very much
17. I have confidence in my doctor(s)
18. My doctor is available to answer my questions
19. Looking at the above 2 questions, how much would you say your Relationship with the Doctor affects your quality of life?

During the past 7 days:

Emotional Well-Being

	not at all	a little bit	some what	quite a bit	very much
20. I feel sad
21. I am proud of how I’m coping with my illness
22. I am losing hope in the fight against my illness
23. I feel nervous
24. I worry about dying
25. I worry that my condition will get worse
26. Looking at the above 6 questions, how much would you say your Emotional Well-Being affects your quality of life?

During the past 7 days:

Functional Well-Being

	not at all	a little bit	some what	quite a bit	very much
27. I am able to work (including my work at home)
28. My work (including my work at home) is fulfilling
29. I am able to enjoy life
30. I have accepted my illness
31. I am sleeping well
32. I am enjoying the things I usually do for fun
33. I am content with the quality of my life right now
34. Looking at the above 7 questions, how much would you say your Functional Well Being affects your quality of life? (not at all)

THANK YOU