qs CRFs

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Example Case Report Forms for QS domain

Form: EQ-5D-3L

Question	Response
Date Collected	QS.QSDTC
Perfomed	Yes No QS.QSSTAT
Reason if not performed	QS.QSREASND
Mobility	I have no problems in walking about I have some problems in walking about I am confined to bed "QS.QSORRES when QS.QSTESTCD=""EQ5D101"""
Self-care	I have no problems with self-care I have some problems washing or dressing myself I am unable to wash or dress myself "QS.QSORRES when QS.QSTESTCD=""EQ5D102"""
Usual activities	I have no problems with performing my usual activities I have some problems with performing my usual activities I am unable to perform my usual activities "QS.QSORRES when QS.QSTESTCD=""EQ5D103"""
Pain/Discomfort	I have no pain or discomfort I have moderate pain or discomfort I have extreme pain or discomfort "QS.QSORRES when QS.QSTESTCD=""EQ5D104"""
Anxiety/Depression	I am not anxious or depressed I am moderately anxious or depressed I am extremely anxious or depressed "QS.QSORRES when QS.QSTESTCD=""EQ5D105"""
Health state Visual Analog Score	"QS.QSORRES when QS.QSTESTCD=""EQ5D106"""

Form: EQ-5D-5L

Question	Response
Date Collected	QS.QSDTC
Perfomed	Yes No QS.QSSTAT
Reason if not performed	QS.QSREASND
Mobility	I have no problems walking I have slight problems walking I have moderate problems walking I have severe problems walking I am unable to walk "QS.QSORRES when QS.QSTESTCD=""EQ5D201"""
Self-care	I have no problems washing or dressing myself I have slight problems washing or dressing myself I have moderate problems washing or dressing myself I have severe problems washing or dressing myself I am unable to wash or dress myself "QS.QSORRES when QS.QSTESTCD=""EQ5D202"""
Usual activities	I have no problems doing my usual activities I have slight problems doing my usual activities I have moderate problems doing my usual activities I have severe problems doing my usual activities I am unable to do my usual activities "QS.QSORRES when QS.QSTESTCD=""EQ5D203"""
Pain/Discomfort	I have no pain or discomfort I have slight pain or discomfort I have moderate pain or discomfort I have severe pain or discomfort I have extreme pain or discomfort "QS.QSORRES when QS.QSTESTCD=""EQ5D204"""
Anxiety/Depression	I am not anxious or depressed I am slightly anxious or depressed I am moderately anxious or depressed I am severely anxious or depressed I am extremely anxious or depressed "QS.QSORRES when QS.QSTESTCD=""EQ5D205"""
Health state Visual Analog Score	"QS.QSORRES when QS.QSTESTCD=""EQ5D206"""

Form: Mini-Mental State Examination Summary

Question	Response
A. Orientation - Time (Range of
A. Orientation - Place (Range of
B. Registration (Range of score
C. Attention and Calculation (Ra
D. Recall (Range of score is 0 t
E. Language (Range of score is 0
Sum of scores for Sections A thr

Form: ECOG Performacne Status

Question	Response
Date of assessment	QS.QSDTC
Subject ECOG status	Grade 0: Fully active, able to carry on all pre-disease performance without restriction\|Grade 1: Restricted in physically
	"QSCAT=""EOCG"""

Form: Health Assessment Questionnaire - Disability Index

Question	Response
Date of assessment	QS.QSDTC
Dressing & Grooming
Dress yourself, including tying	Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do
Shampoo your hair?	Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do
Arising
Stand up from an armless chair?	Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do
Get in and out of bed?	Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do
Eating
Cut up your own meat?	Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do
Lift a full cup or glass to your	Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do
Open a new carton of milk (or so	Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do
Walking
Walk outdoors on flat ground?	Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do
Climb up five steps?	Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do
AIDS or DEVICES that you usually
Devices used for Dressing (butto	Yes No
Cane (W)	Yes No
Walking Frame (W)	Yes No
Crutches (W)	Yes No
Wheel Chair (W)	Yes No
Special or built up chair (A)	Yes No
Built up or special utensils (E)	Yes No
Any other devices used?	Yes No
Specify if any other device is u
Any categories for which help is
Dressing and Grooming	Yes No
Arising	Yes No
Eating	Yes No
Walking	Yes No
Hygiene
Wash and dry your entire body?	Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do
Take a bath?	Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do
Get on and off the toilet?	Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do
Reach
Reach and get down a 5 lb object	Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do
Bend down to pick up clothing of	Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do
Grip
Open car doors?	Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do
Open jars which have been previo	Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do
Turn taps on and off?	Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do
Activities
Run errands and shop?	Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do
Get in and out of a car?	Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do
Do chores such as vacuuming, hou	Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do
any AIDS or DEVICES that you usu
Raised toilet seat (H)	Yes No
Bath seat (H)	Yes No
Bath rail (H)	Yes No
Long-handled appliances for reac	Yes No
Jar opener (for jars previously	Yes No
Any categories for which help is
Hygiene	Yes No
Reach	Yes No
Gripping and opening things	Yes No
Errands or housework	Yes No
how well you are doing on a scal
How much pain have you had IN TH

Form: SF 36 Health Survey

Question	Response
Date of assessment	QS.QSDTC
1. In general, would you say you	Excellent Very Good Good Fair Poor
2. Compared to one year ago, how	Much better now than one year ago Somewhat better now than one year ago About the same as one year ago Somewhat worse now than one year ago Much worse now than one year ago
3.a. Vigorous activities, such a	Yes, limited a lot Yes, limited a little No, not limited at all
3.b. Moderate activities, such a	Yes, limited a lot Yes, limited a little No, not limited at all
3.c. Lifting or carrying groceri	Yes, limited a lot Yes, limited a little No, not limited at all
3.d. Climbing several flights of	Yes, limited a lot Yes, limited a little No, not limited at all
3.e. Climbing one flight of stai	Yes, limited a lot Yes, limited a little No, not limited at all
3.f. Bending, kneeling, or stoop	Yes, limited a lot Yes, limited a little No, not limited at all
3.g. Walking more than a mile	Yes, limited a lot Yes, limited a little No, not limited at all
3.h. Walking several hundred yar	Yes, limited a lot Yes, limited a little No, not limited at all
3.i. Walking one hundred yards	Yes, limited a lot Yes, limited a little No, not limited at all
3.j. Bathing or dressing yoursel	Yes, limited a lot Yes, limited a little No, not limited at all
4.a. Cut down on the amount of t	All of the time Most of the time Some of the time A little of the time None of the time
4.b. Accomplished less than you	All of the time Most of the time Some of the time A little of the time None of the time
4.c. Were limited in the kind of	All of the time Most of the time Some of the time A little of the time None of the time
4.d. Had difficulty performing t	All of the time Most of the time Some of the time A little of the time None of the time
5.a. Cut down on the amount of t	All of the time Most of the time Some of the time A little of the time None of the time
5.b. Accomplished less than you	All of the time Most of the time Some of the time A little of the time None of the time
5.c. Didn't do work or other act	All of the time Most of the time Some of the time A little of the time None of the time
6. During the past 4 weeks, to w	Not at all Slightly Moderately Quite a bit Extremely
7. How much bodily pain have you	None Very mild Mild Moderate Severe Very severe
8. During the past 4 weeks, how	Not at all Slightly Moderately Quite a bit Extremely
9.a. Did you feel full of life?	All of the time Most of the time Some of the time A little of the time None of the time
9.b. Have you been very nervous?	All of the time Most of the time Some of the time A little of the time None of the time
9.c. Have you felt so down in th	All of the time Most of the time Some of the time A little of the time None of the time
9.d. Have you felt calm and peac	All of the time Most of the time Some of the time A little of the time None of the time
9.e. Did you have a lot of energ	All of the time Most of the time Some of the time A little of the time None of the time
9.f. Have you felt downhearted a	All of the time Most of the time Some of the time A little of the time None of the time
9.g. Did you feel worn out?	All of the time Most of the time Some of the time A little of the time None of the time
9.h. Have you been happy?	All of the time Most of the time Some of the time A little of the time None of the time
9.i. Did you feel tired?	All of the time Most of the time Some of the time A little of the time None of the time
10. During the past 4 weeks, how	All of the time Most of the time Some of the time A little of the time None of the time
11.a. I seem to get sick a littl	Definitely true Mostly true Mostly false Definitely false
11.b. I am as healthy as anyone	Definitely true Mostly true Mostly false Definitely false
11.c. I expect my health to get	Definitely true Mostly true Mostly false Definitely false
11.d. My health is excellent	Definitely true Mostly true Mostly false Definitely false

Form: Work Productivity and Activity Impairment: Anemic Symptoms

Question	Response
Date of assessment
1. Are you currently employed (w	NO YES
2. During the past seven days, h
3. During the past seven days, h
4. During the past seven days, h
5. During the past seven days, h
6. During the past seven days, h