Example EORTC QLQ-C30 Survey Questionnaire

Cancer Quality of Life Questionnaire
Help us understand what we are doing right, what needs improving and anything else you would like to tell us

This is a fully functional survey e-questionnaire so you can try it out for completion. However, we do not analyse the results of this example survey

Question Title

1. Do you have any trouble doing strenuous activities, like carrying a heavy shopping bag or a suitcase?

1 = Not at all

2 = A little

3 = Quite a bit

4 = Very much

Question Title

2. Do you have any trouble taking a long walk?

1 = Not at all

2 = A little

3 = Quite a bit

4 = Very much

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3. Do you have any trouble taking a short walk outside of the house?

1 = Not at all

2 = A little

3 = Quite a bit

4 = Very much

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4. Do you need to stay in bed or a chair during the day?

1 = Not at all

2 = A little

3 = Quite a bit

4 = Very much

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5. Do you need help with eating, dressing, washing yourself or using the toilet?

1 = Not at all

2 = A little

3 = Quite a bit

4 = Very much

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6. Were you limited in doing either your work or their daily activities?

1 = Not at all

2 = A little

3 = Quite a bit

4 = Very much

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7. Were you limited in pursuing your hobbies or other leisure time activities?

1 = Not at all

2 = A little

3 = Quite a bit

4 = Very much

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8. Were you short of breath?

1 = Not at all

2 = A little

3 = Quite a bit

4 = Very much

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9. Have you had pain?

1 = Not at all

2 = A little

3 = Quite a bit

4 = Very much

Question Title

10. Did you need to rest?

1 = Not at all

2 = A little

3 = Quite a bit

4 = Very much

Question Title

11. Have you had trouble sleeping?

1 = Not at all

2 = A little

3 = Quite a bit

4 = Very much

Question Title

12. Have you felt weak?

1 = Not at all

2 = A little

3 = Quite a bit

4 = Very much

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13. Have you lacked appetite?

1 = Not at all

2 = A little

3 = Quite a bit

4 = Very much

Question Title

14. Have you felt nauseated?

1 = Not at all

2 = A little

3 = Quite a bit

4 = Very much

Question Title

15. Have you vomited?

1 = Not at all

2 = A little

3 = Quite a bit

4 = Very much

Question Title

16. Have you been constipated?

1 = Not at all

2 = A little

3 = Quite a bit

4 = Very much

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17. Have you had diarrhoea?

1 = Not at all

2 = A little

3 = Quite a bit

4 = Very much

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18. Were you tired?

1 = Not at all

2 = A little

3 = Quite a bit

4 = Very much

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19. Did pain interfere with your daily activities?

1 = Not at all

2 = A little

3 = Quite a bit

4 = Very much

Question Title

20. Have you had difficulty in concentrating on things. like reading a newspaper or watching television?

1 = Not at all

2 = A little

3 = Quite a bit

4 = Very much

Question Title

21. Did you feel tense?

1 = Not at all

2 = A little

3 = Quite a bit

4 = Very much

Question Title

22. Did you worry?

1 = Not at all

2 = A little

3 = Quite a bit

4 = Very much

Question Title

23. Did you feel irritable?

1 = Not at all

2 = A little

3 = Quite a bit

4 = Very much

Question Title

24. Did you feel depressed?

1 = Not at all

2 = A little

3 = Quite a bit

4 = Very much

Question Title

25. Have you had difficulty remembering things?

1 = Not at all

2 = A little

3 = Quite a bit

4 = Very much

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26. Has your physical condition or medical treatment interfered with your family life?

1 = Not at all

2 = A little

3 = Quite a bit

4 = Very much

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27. Has your physical condition or medical treatment interfered with your social activities?

1 = Not at all

2 = A little

3 = Quite a bit

4 = Very much

Question Title

28. Has your physical condition or medical treatment caused you financial difficulties?

1 = Not at all

2 = A little

3 = Quite a bit

4 = Very much

Question Title

29. How would you rate your overall health during the past week?

1 — Very Poor

2 — Poor

3 — Fair

4 — Average

5 — Good

6 — Very Good

7 — Excellent

Question Title

30. How would you rate your overall quality of life during the past week?

1 — Very Poor

2 — Poor

3 — Fair

4 — Average

5 — Good

6 — Very Good

7 — Excellent

Example EORTC QLQ-C30 Survey Questionnaire

Question Title

* 1. Do you have any trouble doing strenuous activities, like carrying a heavy shopping bag or a suitcase?

Question Title

* 2. Do you have any trouble taking a long walk?

Question Title

* 3. Do you have any trouble taking a short walk outside of the house?

Question Title

* 4. Do you need to stay in bed or a chair during the day?

Question Title

* 5. Do you need help with eating, dressing, washing yourself or using the toilet?

Question Title

* 6. Were you limited in doing either your work or their daily activities?

Question Title

* 7. Were you limited in pursuing your hobbies or other leisure time activities?

Question Title

* 8. Were you short of breath?

Question Title

* 9. Have you had pain?

Question Title

* 10. Did you need to rest?

Question Title

* 11. Have you had trouble sleeping?

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* 12. Have you felt weak?

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* 13. Have you lacked appetite?

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* 14. Have you felt nauseated?

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* 15. Have you vomited?

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* 16. Have you been constipated?

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* 17. Have you had diarrhoea?

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* 18. Were you tired?

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* 19. Did pain interfere with your daily activities?

Question Title

* 20. Have you had difficulty in concentrating on things. like reading a newspaper or watching television?

Question Title

* 21. Did you feel tense?

Question Title

* 22. Did you worry?

Question Title

* 23. Did you feel irritable?

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* 24. Did you feel depressed?

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* 25. Have you had difficulty remembering things?

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* 26. Has your physical condition or medical treatment interfered with your family life?

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* 27. Has your physical condition or medical treatment interfered with your social activities?

Question Title

* 28. Has your physical condition or medical treatment caused you financial difficulties?

Question Title

* 29. How would you rate your overall health during the past week?

Question Title

* 30. How would you rate your overall quality of life during the past week?

1. Do you have any trouble doing strenuous activities, like carrying a heavy shopping bag or a suitcase?

2. Do you have any trouble taking a long walk?

3. Do you have any trouble taking a short walk outside of the house?

4. Do you need to stay in bed or a chair during the day?

5. Do you need help with eating, dressing, washing yourself or using the toilet?

6. Were you limited in doing either your work or their daily activities?

7. Were you limited in pursuing your hobbies or other leisure time activities?

8. Were you short of breath?

9. Have you had pain?

10. Did you need to rest?

11. Have you had trouble sleeping?

12. Have you felt weak?

13. Have you lacked appetite?

14. Have you felt nauseated?

15. Have you vomited?

16. Have you been constipated?

17. Have you had diarrhoea?

18. Were you tired?

19. Did pain interfere with your daily activities?

20. Have you had difficulty in concentrating on things. like reading a newspaper or watching television?

21. Did you feel tense?

22. Did you worry?

23. Did you feel irritable?

24. Did you feel depressed?

25. Have you had difficulty remembering things?

26. Has your physical condition or medical treatment interfered with your family life?

27. Has your physical condition or medical treatment interfered with your social activities?

28. Has your physical condition or medical treatment caused you financial difficulties?

29. How would you rate your overall health during the past week?

30. How would you rate your overall quality of life during the past week?