3M survey
DCS-C Quality of Life Questionnaire
ABOUT THIS QUESTIONNAIRE
These questions ask about you, your disability or condition, and its treatment.
Please think carefully about each question. They can be answered simply by checking the line or circling the number next to the answer which best applies to you.
If you are unsure how to answer any questions, please give the best answer you can and write in any comments you want to make.
Part 1. Please provide the following information about yourself:
1. How old are you (in years)? Years
2. Are you female or male?
2a. What is your disability or chronic illness?
3. Which item best describes your race (ethnic group)?
African American
Native American
Asian or Pacific Islander
White (non-Hispanic)
Hispanic
Other:
4. What is your marital status ?
married or living as married
divorced
Separated
never married
Widowed
other
5. Which of the following best describes your highest level of education ?
Less than high school
College graduate
High school grad. or equivalent
Master’s degree or higher
Some college or technical school
6. Which of the following best describes your position about paid work?
Employed full-time
Employed Part-Time
Unemployed- Seeking work
Homemaker
Student
Permanent Disability
Retired
Number of hours per week:
7. What is your approximate monthly household income ?
Less than $500
$2,000- 2,999
$500 - 999
$3,000 – 3,999
$1,000 - 1,999
over $4000
1. If you have a disability or condition that affects your ability to function as you would like to, please label it here:
How old were you when you were diagnosed or started experiencing this condition?
years
3. At the present time how disabled are you by your condition?
Fully Dependent on
Independent others for all care
1
2
3
4
5
6
7
8
9
10
4. Do you have any other medical conditions or illnesses?
Yes No
If ‘Yes’ please describe:
___________________________________________________________
Part 3. Your Quality of Life:
Check the box which best describes how you feel about YOUR LIFE AS A WHOLE
Very Very
Bad Good
Part 4. Ladder of Adjustment
Suppose that a person's overall adjustment to a disability could be shown on a ladder having 10 steps with the tenth step representing the best possible adjustment and the first representing the worst possible. On what step of the ladder would you place yourself to indicate your current overall adjustment (1-10) (check one)?
10 – Best Possible Adjustment
_____ 9
_____ 8
_____ 7
_____ 6
_____ 5
_____ 4
_____ 3
_____ 2
_____ 1 – Worst Possible Adjustment
Where on the ladder do you expect yourself to be in five years (1-10) (check one)?
10-Best Possible Adjustment
Part 5. Disability Centrality Scale
Finally, we would like to think about a number of different areas of your life, including things like your physical health, emotional health, your relationships with family and friends, your work, and so on. For each of the 10 parts of your life on the next few pages, please answer the following questions by clicking on the circle of the number that is right for you. The questions ask about:
1. Importance: How important is this part of your life in contributing to your overall quality of life?
2. Satisfaction: How satisfied are you with how this part of your life is going?
3. Control: How much control do you have over this part of your life? In other words: How much do you feel like you
could change things in this part of your life if you wanted to?
4. Interference: How much does your illness or disability and/or its treatment
interfere with your ability to function in this area of your life as you would like to?
1. Your Physical Health
Not Very 1 2 3 4 5 6 7 Very
Important Important
Satisfied Satisfied
Not Very Much 1 2 3 4 5 6 7 Very Much
2. Your Mental Health (e.g., Emotional well-being, happiness, enjoyment of life)
Not Very Satisfied 1 2 3 4 5 6 7 Very Satisfied
3. Your Work (or, if a student, your Studies)
4. Your Leisure Activities (e.g., Sports, hobbies, things you do to relax or have fun)
5. Your Financial Situation
6. Relationship with your spouse or partner
7. Family Relations (Your relationships with your children, siblings, or parents)
8. Other Social Relations (e.g., Friends, people who offer you support)