UTERINE FIBROID SYMPTOM & HEALTH-RELATEDQUALITY OF LIFE QUESTIONNAIRE (UFS-QOL)
Listed below are symptoms experienced by women who have uterine fibroids. Please consider each symptom as it relates to your uterine fibroids or menstrual cycle. Each question asks how much distress you have experienced from each symptom during the previous three months.There are no right or wrong answers. Please be sure to answer every question by checking the most appropriate box. If a question does not apply to you, please mark “not at all” as a response.
Patient Name
*
First Name
Last Name
DOB
-
Month
-
Day
Year
Date
Time since fibroid treatment
No treatment yet
3 months
6 months
9 months
1 year
2 years
3 years
During the previous three months, how distressed were you by:
1. Heavy bleeding during your menstrual period
*
Please Select
Not at all (1)
A little (2)
Somewhat (3)
A great deal (4)
A very great deal (5)
2. Passing blood clots during your menstrual period
*
Please Select
Not at all (1)
A little (2)
Somewhat (3)
A great deal (4)
A very great deal (5)
3. Fluctuation in the duration of your menstrual period
*
Please Select
Not at all (1)
A little (2)
Somewhat (3)
A great deal (4)
A very great deal (5)
4. Fluctuation in the length of your monthly cycle compared to your previous cycles
*
Please Select
Not at all (1)
A little (2)
Somewhat (3)
A great deal (4)
A very great deal (5)
5. Feeling tightness or pressure in your pelvic area
*
Please Select
Not at all (1)
A little (2)
Somewhat (3)
A great deal (4)
A very great deal (5)
6. Frequent urination during the daytime hours
*
Please Select
Not at all (1)
A little (2)
Somewhat (3)
A great deal (4)
A very great deal (5)
7. Frequent nighttime urination
*
Please Select
Not at all (1)
A little (2)
Somewhat (3)
A great deal (4)
A very great deal (5)
8. Feeling fatigued
*
Please Select
Not at all (1)
A little (2)
Somewhat (3)
A great deal (4)
A very great deal (5)
The following questions ask about your feelings and experiences regarding the impact of uterinefibroid symptoms on your life. Please consider each question as it relates to your experiences withuterine fibroids during the previous three months.There are no right or wrong answers. Please be sure to answer every question by checking themost appropriate box. If a question does not apply to you, please mark “none of the time” as your option. During the previous three months, how often have your symptoms related to uterine fibroids?
9. Made you feel anxious about the unpredictable onset or duration of your periods?
*
Please Select
None of the time (1)
A little of the time (2)
Some of the time (3)
Most of the time (4)
All of the time (5)
10. Made you feel anxious about traveling?
*
Please Select
None of the time (1)
A little of the time (2)
Some of the time (3)
Most of the time (4)
All of the time (5)
11. Interfered with your physical activities?
*
Please Select
None of the time (1)
A little of the time (2)
Some of the time (3)
Most of the time (4)
All of the time (5)
12. Caused you to feel tired or worn out?
*
Please Select
None of the time (1)
A little of the time (2)
Some of the time (3)
Most of the time (4)
All of the time (5)
13. Made you decrease the amount of time you spent on exercise or other physical activities?
*
Please Select
None of the time (1)
A little of the time (2)
Some of the time (3)
Most of the time (4)
All of the time (5)
14. Made you feel as if you are not in control of your life?
*
Please Select
None of the time (1)
A little of the time (2)
Some of the time (3)
Most of the time (4)
All of the time (5)
15. Made you concerned about soiling underclothes?
*
Please Select
None of the time (1)
A little of the time (2)
Some of the time (3)
Most of the time (4)
All of the time (5)
16. Made you less productive?
*
Please Select
None of the time (1)
A little of the time (2)
Some of the time (3)
Most of the time (4)
All of the time (5)
17. Caused you to feel drowsy or sleepy during the day?
*
Please Select
None of the time (1)
A little of the time (2)
Some of the time (3)
Most of the time (4)
All of the time (5)
18. Made you feel self-conscious of weight gain?
*
Please Select
None of the time (1)
A little of the time (2)
Some of the time (3)
Most of the time (4)
All of the time (5)
19. Made you feel that it was difficult to carry out your usual activities?
*
Please Select
None of the time (1)
A little of the time (2)
Some of the time (3)
Most of the time (4)
All of the time (5)
20. Interfered with your social activities?
*
Please Select
None of the time (1)
A little of the time (2)
Some of the time (3)
Most of the time (4)
All of the time (5)
21. Made you feel conscious about the size and appearance of your stomach?
*
Please Select
None of the time (1)
A little of the time (2)
Some of the time (3)
Most of the time (4)
All of the time (5)
22. Made you concerned about soiling bed linen?
*
Please Select
None of the time (1)
A little of the time (2)
Some of the time (3)
Most of the time (4)
All of the time (5)
23. Made you feel sad, discouraged or hopeless?
*
Please Select
None of the time (1)
A little of the time (2)
Some of the time (3)
Most of the time (4)
All of the time (5)
24. Made you feel down-hearted and blue?
*
Please Select
None of the time (1)
A little of the time (2)
Some of the time (3)
Most of the time (4)
All of the time (5)
25. Made you feel wiped out?
*
Please Select
None of the time (1)
A little of the time (2)
Some of the time (3)
Most of the time (4)
All of the time (5)
26. Caused you to be concerned or worried about your health?
*
Please Select
None of the time (1)
A little of the time (2)
Some of the time (3)
Most of the time (4)
All of the time (5)
27. Caused you to plan activities more carefully?
*
Please Select
None of the time (1)
A little of the time (2)
Some of the time (3)
Most of the time (4)
All of the time (5)
28. Made you feel inconvenienced always carrying extra pads, tampons, and clothing to avoid accidents?
*
Please Select
None of the time (1)
A little of the time (2)
Some of the time (3)
Most of the time (4)
All of the time (5)
29. Caused you embarrassment?
*
Please Select
None of the time (1)
A little of the time (2)
Some of the time (3)
Most of the time (4)
All of the time (5)
30. Made you feel uncertain about your future?
*
Please Select
None of the time (1)
A little of the time (2)
Some of the time (3)
Most of the time (4)
All of the time (5)
31. Made you irritable?
*
Please Select
None of the time (1)
A little of the time (2)
Some of the time (3)
Most of the time (4)
All of the time (5)
32. Affected the size of clothing you wear during your periods?
*
Please Select
None of the time (1)
A little of the time (2)
Some of the time (3)
Most of the time (4)
All of the time (5)
33. Made you feel that you are not in control of your health?
*
Please Select
None of the time (1)
A little of the time (2)
Some of the time (3)
Most of the time (4)
All of the time (5)
34. Made you feel weak as if energy was drained from your body?
*
Please Select
None of the time (1)
A little of the time (2)
Some of the time (3)
Most of the time (4)
All of the time (5)
35. Made you concerned about soiling outer clothes?
*
Please Select
None of the time (1)
A little of the time (2)
Some of the time (3)
Most of the time (4)
All of the time (5)
36. Diminished your sexual desire?
*
Please Select
None of the time (1)
A little of the time (2)
Some of the time (3)
Most of the time (4)
All of the time (5)
37. Caused you to avoid sexual relations?
*
Please Select
None of the time (1)
A little of the time (2)
Some of the time (3)
Most of the time (4)
All of the time (5)
Date
-
Month
-
Day
Year
Date
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