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

 

Part 2. Information About Your Disability or Condition

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

1

 

2

 

3

 

4

 

5

 

6

 

7

 

8

 

9

 

10

 

 

 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

      _____  9

           _____  8

                _____  7

                       _____  6

                          _____ 5

                               _____  4

                                    _____  3

                                         _____  2

                                               _____  1 – Worst 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

 

IMPORTANCE

Not Very             1          2          3          4          5          6          7                Very

Important                                                               Important

                          

SATISFACTION

Not Very             1          2          3          4          5          6          7              Very

Satisfied                                                                Satisfied

 

CONTROL

Not Very Much        1          2          3          4          5          6          7            Very Much

                                                                     

 

INTERFERENCE

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)

 

IMPORTANCE

Not Very               1          2          3          4          5          6          7          Very

Important                                                           Important

 

SATISFACTION

Not Very Satisfied              1          2          3          4          5          6          7           Very Satisfied

                                                                               

 

CONTROL

Not Very Much                  1          2          3          4          5          6          7            Very Much

                                                                               

 

INTERFERENCE

Not Very Much                 1          2          3          4          5          6          7             Very Much

                                                                              

 

 

3. Your Work  (or, if a student, your Studies)

 

IMPORTANCE

Not Very               1          2          3          4          5          6          7             Very

Important                                                              Important

 

SATISFACTION

Not Very Satisfied              1          2          3          4          5          6          7           Very Satisfied

                                                                                

 

CONTROL

Not Very Much                  1          2          3          4          5          6          7            Very Much

                                                                                

 

INTERFERENCE

Not Very Much                 1          2          3          4          5          6          7             Very Much

                                                                               

 

 

4.  Your Leisure Activities (e.g., Sports, hobbies, things you do to relax or have fun)

 

IMPORTANCE

Not Very                1          2          3          4          5          6          7             Very

Important                                                               Important

 

SATISFACTION

Not Very Satisfied              1          2          3          4          5          6          7           Very Satisfied

                                                                               

 

CONTROL

Not Very Much                  1          2          3          4          5          6          7            Very Much

                                                                                

 

INTERFERENCE

Not Very Much                 1          2          3          4          5          6          7             Very Much

                                                                              

 

 

5.  Your Financial Situation

 

IMPORTANCE

Not Very               1          2          3          4          5          6          7             Very

Important                                                               Important

 

SATISFACTION

Not Very Satisfied              1          2          3          4          5          6          7           Very Satisfied

                                                                                

 

CONTROL

Not Very Much                  1          2          3          4          5          6          7            Very Much

                                                                                

 

INTERFERENCE

Not Very Much                 1          2          3          4          5          6          7             Very Much

                                                                               

 

 

6. Relationship with your spouse or partner

 

IMPORTANCE

Not Very                1          2          3          4          5          6          7             Very

Important                                                               Important

 

SATISFACTION

Not Very Satisfied              1          2          3          4          5          6          7           Very Satisfied

                                                                               

 

CONTROL

Not Very Much                  1          2          3          4          5          6          7            Very Much

                                                                               

 

INTERFERENCE

Not Very Much                 1          2          3          4          5          6          7             Very Much

                                                                               

 

 

 

7. Family Relations (Your relationships with your children, siblings, or parents)

 

IMPORTANCE

Not Very                1          2          3          4          5          6          7          Very

Important                                                           Important

 

SATISFACTION

Not Very Satisfied              1          2          3          4          5          6          7           Very Satisfied

                                                                                

 

CONTROL

Not Very Much                  1          2          3          4          5          6          7            Very Much

                                                                                

 

INTERFERENCE

Not Very Much                 1          2          3          4          5          6          7             Very Much

                                                                              

 

 

8. Other Social Relations (e.g., Friends, people who offer you support)

 

IMPORTANCE

Not Very                1          2          3          4          5          6          7         Very

Important                                                            Important

 

SATISFACTION

Not Very Satisfied              1          2          3          4          5          6          7           Very Satisfied

                                                                               

 

CONTROL

Not Very Much                  1          2          3          4          5          6          7            Very Much

                                                                                

 

INTERFERENCE

Not Very Much                 1          2          3          4          5          6          7             Very Much