Suggested Data Collection Forms Page 2
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4QUALITY OF LIFE QUESTIONNAIRE (administered preoperatively and postoperatively)
Generally speaking, how would you rate your quality of life currently?
1–Excellent
2–Very good
3–Good
4 –Poor/inferior
5–Very poor
Using the same scale as above (1–5), how would you rate the following activities currently:
Writing
1
2
3
4
5
Manual work
1
2
3
4
5
Leisure
1
2
3
4
5
Sports
1
2
3
4
5
Hand shaking
1
2
3
4
5
Socializing
1
2
3
4
5
Grasping objects
1
2
3
4
5
Social dancing
1
2
3
4
5
PERSONAL DOMAIN—with partner/spouse, how would you rate your quality of life:
Holding hands
1
2
3
4
5
Intimate touching
1
2
3
4
5
Intimate affairs
1
2
3
4
5
EMOTIONAL-SELF/OTHERS— how would you rate the fact that after sweating excessively:
I have always justified myself
1
2
3
4
5
People rejected me slightly
1
2
3
4
5
UNDER SPECIAL CIRCUMSTANCES— how would you rate the quality of your life:
In a closed or hot environment
1
2
3
4
5
When tense or worried
1
2
3
4
5
Thinking about the problem
1
2
3
4
5
Before a test, meeting, or public speaking
1
2
3
4
5
Wearing sandals/barefoot
1
2
3
4
5
Wearing colored clothing
1
2
3
4
5
Having problems at school/work
1
2
3
4
5
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