PHYSICAL WELL-BEING | Not at all | A little bit | Some-what | Quite a bit | Very much | |
GP1 | I have a lack of energy | 0 | 1 | 2 | 3 | 4 |
GP2 | I have nausea | 0 | 1 | 2 | 3 | 4 |
GP3 | Because of my physical condition, I have trouble meeting the needs of my family | 0 | 1 | 2 | 3 | 4 |
GP4 | I have pain | 0 | 1 | 2 | 3 | 4 |
GP5 | I am bothered by side effects of treatment | 0 | 1 | 2 | 3 | 4 |
GP6 | I feel ill | 0 | 1 | 2 | 3 | 4 |
GP7 | I am forced to spend time in bed | 0 | 1 | 2 | 3 | 4 |
SOCIAL/FAMILY WELL-BEING | Not at all | A little bit | Some-what | Quite a bit | Very much | |
GS1 | I feel close to my friends | 0 | 1 | 2 | 3 | 4 |
GS2 | I get emotional support from my family | 0 | 1 | 2 | 3 | 4 |
GS3 | I get support from my friends | 0 | 1 | 2 | 3 | 4 |
GS4 | My family has accepted my illness | 0 | 1 | 2 | 3 | 4 |
GS5 | I am satisfied with family communication about my illness | 0 | 1 | 2 | 3 | 4 |
GS6 | I feel close to my partner (or the person who is my main support) | 0 | 1 | 2 | 3 | 4 |
Q1 | Regardless of your current level of sexual activity, please answer the following question. If you prefer not to answer it, please mark this box and go to the next section. | |||||
GS7 | I am satisfied with my sex life | 0 | 1 | 2 | 3 | 4 |
EMOTIONAL WELL-BEING | Not at all | A little bit | Some-what | Quite a bit | Very much | |
GE1 | I feel sad | 0 | 1 | 2 | 3 | 4 |
GE2 | I am satisfied with how I am coping with my illness | 0 | 1 | 2 | 3 | 4 |
GE3 | I am losing hope in the fight against my illness | 0 | 1 | 2 | 3 | 4 |
GE4 | I feel nervous | 0 | 1 | 2 | 3 | 4 |
GE5 | I worry about dying | 0 | 1 | 2 | 3 | 4 |
GE6 | I worry that my condition will get worse | 0 | 1 | 2 | 3 | 4 |
FUNCTIONAL WELL-BEING | Not at all | A little bit | Some-what | Quite a bit | Very much | |
GF1 | I am able to work (include work at home) | 0 | 1 | 2 | 3 | 4 |
GF2 | My work (include work at home) is fulfilling | 0 | 1 | 2 | 3 | 4 |
GF3 | I am able to enjoy life | 0 | 1 | 2 | 3 | 4 |
GF4 | I have accepted my illness | 0 | 1 | 2 | 3 | 4 |
GF5 | I am sleeping well | 0 | 1 | 2 | 3 | 4 |
GF6 | I am enjoying the things I usually do for fun | 0 | 1 | 2 | 3 | 4 |
GF7 | I am content with the quality of my life right now | 0 | 1 | 2 | 3 | 4 |
ADDITIONAL CONCERNS | Not at all | A little bit | Some-what | Quite a bit | Very much | |
BMT1 | I am concerned about keeping my job (include work at home) | 0 | 1 | 2 | 3 | 4 |
BMT2 | I feel distant from other people | 0 | 1 | 2 | 3 | 4 |
BMT3 | I worry that the transplant will not work | 0 | 1 | 2 | 3 | 4 |
BMT4 | The effects of treatment are worse than I had imagined | 0 | 1 | 2 | 3 | 4 |
C6 | I have a good appetite | 0 | 1 | 2 | 3 | 4 |
C7 | I like the appearance of my body | 0 | 1 | 2 | 3 | 4 |
BMT5 | I am able to get around by myself | 0 | 1 | 2 | 3 | 4 |
BMT6 | I get tired easily | 0 | 1 | 2 | 3 | 4 |
BL4 | I am interested in sex | 0 | 1 | 2 | 3 | 4 |
BMT7 | I have concerns about my ability to have children | 0 | 1 | 2 | 3 | 4 |
BMT8 | I have confidence in my nurse(s) | 0 | 1 | 2 | 3 | 4 |
BMT9 | I regret having the bone marrow transplant | 0 | 1 | 2 | 3 | 4 |
BMT10 | I can remember things | 0 | 1 | 2 | 3 | 4 |
Br1 | I am able to concentrate | 0 | 1 | 2 | 3 | 4 |
BMT11 | I have frequent colds/infections | 0 | 1 | 2 | 3 | 4 |
BMT12 | My eyesight is blurry | 0 | 1 | 2 | 3 | 4 |
BMT13 | I am bothered by a change in the way food tastes | 0 | 1 | 2 | 3 | 4 |
BMT14 | I have tremors | 0 | 1 | 2 | 3 | 4 |
B1 | I have been short of breath | 0 | 1 | 2 | 3 | 4 |
BMT15 | I am bothered by skin problems (e.g., rash, itching) | 0 | 1 | 2 | 3 | 4 |
BMT16 | I have trouble with my bowels | 0 | 1 | 2 | 3 | 4 |
BMT17 | My illness is a personal hardship for my close family members | 0 | 1 | 2 | 3 | 4 |
BMT18 | The cost of my treatment is a burden on me or my family | 0 | 1 | 2 | 3 | 4 |