baseline ufs-qol questionnaire

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

MM

DD

YYYY

1) Heavy menstrual bleeding during your period

Not at all (1)

A little bit (2)

Somewhat (3)

A great deal (4)

A very great deal (5)

2) Passing blood clots during your menstrual period

Not at all (1)

A little bit (2)

Somewhat (3)

A great deal (4)

A very great deal (5)

3) Fluctuation in the duration of your menstrual period compared to your previous cycle

Not at all (1)

A little bit (2)

Somewhat (3)

A great deal (4)

A very great deal (5)

4) Fluctuation in the length of your menstrual cycle compared to your previous cycle

Not at all (1)

A little bit (2)

Somewhat (3)

A great deal (4)

A very great deal (5)

5) Feeling tightness or pressure in your pelvic area

Not at all (1)

A little bit (2)

Somewhat (3)

A great deal (4)

A very great deal (5)

6) Frequent urination during the daytime hours

Not at all (1)

A little bit (2)

Somewhat (3)

A great deal (4)

A very great deal (5)

7) Frequent nighttime urination

Not at all (1)

A little bit (2)

Somewhat (3)

A great deal (4)

A very great deal (5)

8) Feeling fatigued

Not at all (1)

A little bit (2)

Somewhat (3)

A great deal (4)

A very great deal (5)

9) Made you feel anxious about the unpredictable onset or duration of your period

None of the time (1)

A little of the time (2)

Some of the time (3)

Most of the time (4)

All of the time (5)

10) Made you anxious about traveling

None of the time (1)

A little of the time (2)

Some of the time (3)

Most of the time (4)

All of the time (5)

11) Interfered with your physical activities

None of the time (1)

A little of the time (2)

Some of the time (3)

Most of the time (4)

All of the time (5)

12) Caused you to feel tired or worn out

None of the time (1)

A little of the time (2)

Some of the time (3)

Most of the time (4)

All of the time (5)

13) Made you decrease the amount of time you spent on exercise or other physical activities

None of the time (1)

A little of the time (2)

Some of the time (3)

Most of the time (4)

All of the time (5)

14) Made you feel as if you are not control of your life

None of the time (1)

A little of the time (2)

Some of the time (3)

Most of the time (4)

All of the time (5)

15) Made you concerned about soiling your underclothes

None of the time (1)

A little of the time (2)

Some of the time (3)

Most of the time (4)

All of the time (5)

16) Made you feel less productive

None of the time (1)

A little of the time (2)

Some of the time (3)

Most of the time (4)

All of the time (5)

17) Caused you to feel drowsy or sleepy during the day

None of the time (1)

A little of the time (2)

Some of the time (3)

Most of the time (4)

All of the time (5)

18) Made you feel self-conscious of weight gain

None of the time (1)

A little of the time (2)

Some of the time (3)

Most of the time (4)

All of the time (5)

19) Made you feel that it was difficult to carry out your usual activities

None of the time (1)

A little of the time (2)

Some of the time (3)

Most of the time (4)

All of the time (5)

20) Interfered with your social activities

None of the time (1)

A little of the time (2)

Some of the time (3)

Most of the time (4)

All of the time (5)

21) Made you feel conscious about the size and appearance of your stomach

None of the time (1)

A little of the time (2)

Some of the time (3)

Most of the time (4)

All of the time (5)

22) Made you concerned about soiling bed linen

None of the time (1)

A little of the time (2)

Some of the time (3)

Most of the time (4)

All of the time (5)

23) Made you feel sad, discouraged, or helpless

None of the time (1)

A little of the time (2)

Some of the time (3)

Most of the time (4)

All of the time (5)

24) Made you feel down-hearted and blue

None of the time (1)

A little of the time (2)

Some of the time (3)

Most of the time (4)

All of the time (5)

25) Made you feel wiped out

None of the time (1)

A little of the time (2)

Some of the time (3)

Most of the time (4)

All of the time (5)

26) Caused you to be concerned or worried about your health

None of the time (1)

A little of the time (2)

Some of the time (3)

Most of the time (4)

All of the time (5)

27) Caused you to plan activities more carefully

None of the time (1)

A little of the time (2)

Some of the time (3)

Most of the time (4)

All of the time (5)

28) Made you feel inconvenienced about always carrying extra pads, tampons, and clothing to avoid accidents

None of the time (1)

A little of the time (2)

Some of the time (3)

Most of the time (4)

All of the time (5)

29) Caused you embarrassment

None of the time (1)

A little of the time (2)

Some of the time (3)

Most of the time (4)

All of the time (5)

30) Made you feel uncertain about your future

None of the time (1)

A little of the time (2)

Some of the time (3)

Most of the time (4)

All of the time (5)

31) Made you feel irritable

None of the time (1)

A little of the time (2)

Some of the time (3)

Most of the time (4)

All of the time (5)

32) Made you concerned about soiling outer clothes

None of the time (1)

A little of the time (2)

Some of the time (3)

Most of the time (4)

All of the time (5)

33) Affected the size of clothing you were during your periods

None of the time (1)

A little of the time (2)

Some of the time (3)

Most of the time (4)

All of the time (5)

34) Made you feel that you are not in control of your health

None of the time (1)

A little of the time (2)

Some of the time (3)

Most of the time (4)

All of the time (5)

35) Made you feel weak as if energy was drained from your body

None of the time (1)

A little of the time (2)

Some of the time (3)

Most of the time (4)

All of the time (5)

36) Diminished your sexual desire

None of the time (1)

A little of the time (2)

Some of the time (3)

Most of the time (4)

All of the time (5)

37) Caused you to avoid sexual relations

None of the time (1)

A little of the time (2)

Some of the time (3)

Most of the time (4)

All of the time (5)

Attestation *

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

Date of Completion

MM

DD

YYYY