3-month ufs-qol Scoring

Site

Patient Number

Please enter in three digit format (e.g., 001, 002, ..., 025)

Is this an original or revised submission?

Original

Revision

Name of the Person Entering Data into this CRF

First Name

Last Name

UFS-QOL Administration Date

YYYY

UFS-QOL Scoring

Symptom Severity Raw Score (Sum of #1-8)

Transformed Symptom Severity Score = ((Actual SS Raw Score - 8)/32) X 100

Health-Related Quality of Life Score (Sum of #9-37)

Transformed Health-Related Quality of Life Score = ((145 - Actual HRQL Raw Score)/116) X 100)

HRQL Concern Raw Score (Sum of #9 + #15 + #22 + #28 + #32)

Transformed HRQL Concern Score ((25 - HRQL Concern Raw Score)/20) X 100)

HRQL Activities Raw Score (Sum of #10 + #11 + #13 + # 19 + #20 + #27 + #29)

Transformed HRQL Activities Score ((35 - HRQL Activities Raw Score)/28) X 100)

HRQL Energy/Mood Raw Score (Sum of #12 + #17 + #23 + #24 + #25 + #31 + #35)

Transformed HRQL Energy/Mood Score ((35 - HRQL Energy/Mood Raw Score)/28) X 100)

HRQL Control Raw Score (Sum of #14 + #16 + #26 + #30 + #34)

Transformed HRQL Control Score ((25 - HRQL Control Raw Score)/20) X 100)

HRQL Self-Conscious Raw Score (Sum of #18 + #21 + #33)

Transformed HRQL Self-Conscious Score ((15 - HRQL Self-Conscious Raw Score)/12) X 100)

HRQL Sexual Function Raw Score (Sum of #36 + #37)

Transformed HRQL Sexual Function Score ((10 - HRQL Sexual Function Raw Score)/8) X 100)

Attestation

I approve the data entered into this CRF and attest to its accuracy.

Date of Completion

YYYY