Goal

The purpose of this questionnaire is to learn how different health conditions (described in detail in the next sections) may affect quality of life. There are no right or wrong answers — we are interested in your personal opinion.

Data protection and informed consent

Taking part in this questionnaire is completely voluntary. You may stop at any time, without giving a reason and without any negative consequences.

Your privacy and anonymity will always be respected. The data collected in this study will be processed in compliance with the General Data Protection Regulation (EU) 2016/679 (GDPR), which sets forth the rules for the protection of personal data within the European Union, as well as the Spanish Organic Law 3/2018, of December 5, on the Protection of Personal Data and Guarantee of Digital Rights (LOPDGDD), ensuring that your privacy is respected.

The information you provide will be used only for research purposes. All data will be analyzed in aggregate form, so individual participants cannot be identified. Results may be included in reports and scientific publications, always safeguarding your personal information.

Recommendation

For the best experience, we suggest completing this questionnaire on a computer rather than on a phone or tablet, as the format may not display correctly on smaller screens.

For your convenience, you can save your responses and continue answering the questionnaire at a later time at any point. Use the save button at the bottom of the screen.

How to answer

On the next pages, you will be asked to rate how severe different levels of limitation feel within one area (function) of daily life (for example: eating, seeing, or moving around). Each function has several levels, labeled with letters (A, B, C …).

• Level A always means no limitation and has a score of 0.
• The last level in each table means the most severe limitation and has a score of 100.
• Your task is to give each of the levels in between a number from 0 to 100, showing how severe you think that limitation is.
• There are no right or wrong answers. We want to know your own opinion.
• If you think two or more levels are equally severe, you may give them the same number.
• Please try to use the whole range of 0 to 100 so the differences in severity are clear.

In this section, you will see four levels of limitation:

• A = No limitation (score 0)
• D = Severe incontinence (score 100)
• B and C = Intermediate levels

Please read the descriptions of levels B and C carefully. Then, give each of them a value between 0 and 100, showing how severe you think each limitation is compared to A (no limitation = 0) and D (severe incontinence = 100).

In this section, you will see three levels of limitation:

• A = No limitation (score 0)
• C = Most severe limitation (score 100)
• B = Intermediate level

Please read the description of level B carefully. Then, give it a value between 0 and 100, showing how severe you think this limitation is compared to A (no limitation = 0) and C (most severe limitation = 100).

In this section, you will see three levels of limitation:

• A = No limitation (score 0)
• C = Most severe limitation (score 100)
• B = Intermediate level

Please read the description of level B carefully. Then, give it a value between 0 and 100, showing how severe you think this limitation is compared to A (no limitation = 0) and C (most severe limitation = 100).

IIn this section, you will see six levels of limitation:

• A = No limitation (score 0)
• F = Most severe limitation (score 100)
• B, C, D, and E = Intermediate levels

Please read the descriptions of levels B, C, D, and E carefully. Then, give each of them a value between 0 and 100, showing how severe you think each limitation is compared to A (no limitation = 0) and F (most severe limitation = 100).

In this section, you will see six levels of limitation:

• A = No limitation (score 0)
• F = Most severe limitation (score 100)
• B, C, D, and E = Intermediate levels

Please read the descriptions of levels B, C, D, and E carefully. Then, give each of them a value between 0 and 100, showing how severe you think each limitation is compared to A (no limitation = 0) and F (most severe limitation = 100).

In this section, you will see four levels of limitation:

• A = No limitation (score 0)
• D = Severe limitation (score 100)
• B and C = Intermediate levels

Please read the descriptions of levels B and C carefully. Then, give each of them a value between 0 and 100, showing how severe you think each limitation is compared to A (no limitation = 0) and D (severe limitation= 100).

IIn this section, you will see seven levels of limitation:

• A = No limitation (score 0)
• G = Most severe limitation (score 100)
• B, C, D, E and F = Intermediate levels

Please read the descriptions of levels B, C, D, E and F carefully. Then, give each of them a value between 0 and 100, showing how severe you think each limitation is compared to A (no limitation = 0) and G (most severe limitation = 100).

IIn this section, you will see five levels of limitation:

• A = No limitation (score 0)
• E = Most severe limitation (score 100)
• B, C, and D = Intermediate levels

Please read the descriptions of levels B, C, and D carefully. Then, give each of them a value between 0 and 100, showing how severe you think each limitation is compared to A (no limitation = 0) and E (most severe limitation = 100).

In this section, you will see four levels of limitation:

• A = No limitation (score 0)
• D = Severe difficulty (score 100)
• B and C = Intermediate levels

Please read the descriptions of levels B and C carefully. Then, give each of them a value between 0 and 100, showing how severe you think each limitation is compared to A (no limitation = 0) and D (severe difficulty= 100).

In this section, you will see six levels of limitation:

• A = No limitation (score 0)
• F = Most severe limitation (score 100)
• B, C, D, and E = Intermediate levels

Please read the descriptions of levels B, C, D, and E carefully. Then, give each of them a value between 0 and 100, showing how severe you think each limitation is compared to A (no limitation = 0) and F (most severe limitation = 100).

STEP 1: Consider the most severe level for each dimension as listed below:

- EX: Excretory function: severe incontinence
- EAT: Eating: tube feeding required
- SEX: Sexual function: no sexual function
- AMB: Ambulation: severe limitation in amount of walking and stair climbing, including not being able to do it at all
- HAND: Hand and arm function: complete or near paralysis of both limbs
- BEND: Bending and lifting: cannot bend or lift
- VIS1: Visual function: total blindness in one eye
- VIS2: Visual function: total blindness in both eyes
- AUD1: Auditory function: profound or total loss in one ear
- AUD2: Auditory function: profound or total loss in both ears
- SPCH: Speech: severe difficulty
- COG: Cognitive function: complete dependence; limited orientation- including persistence vegetative state

STEP 2: Consider the scale ranging from 0 to 100 where 0 represents No Limitation in Functional Capacity (i.e., healthy).

STEP 3: Identify the state (listed above) which you believe represents the GREATEST impact on everyday living and select 100 next to it's abreviation.

STEP 4: Consider the remaining 11 states and place them on the scale between 0 and 100 according to your judgments of their relative importance.

Again, you may place more than one state on the same number but only if you think they are of equal importance. Where you place the state on the scale should reflect your judgment of the relative severity of the state in terms of its expected impact on overall function in everyday living.