Multiple Sclerosis Quality of Life Survey (MSQOL-54)

Name*
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Email*
INSTRUCTIONS
This survey asks about your health and daily activities. The information that you share on form will be used to monitor your progress in the Live Disease Free program and for research purposes. Your personal information will not be shared or used for promotional purposes. Answer every question by choosing the appropriate answer and corresponding number (1, 2, 3, ...).

If you are unsure about how to answer a question, please give the best answer you can.

Please feel free to ask someone to assist you if you need help reading or filling out the form.
General Health
1. In general, would you say your health is:*
- Excellent (1)
- Very Good (2)
- Good (3)
- Fair (4)
- Poor (5)
2. Compared to one year ago, how would you rate your health in general now?*
- Much better now than one year ago (1)
- Somewhat better now than one year ago (2)
- About the same (3)
- Somewhat worse now than one year ago (4)
- Much worse now than one year ago (5)
Physical Health
The following questions are about activities you might do during a typical day. Does your health limit you in these activities? If so, how much?
3. Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports*
- Yes, Limited a Lot (1)
- Yes, Limited a Little (2)
- No, Not Limited at All (3)
4. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf*
- Yes, Limited a Lot (1)
- Yes, Limited a Little (2)
- No, Not Limited at All (3)
5. Lifting or carrying groceries*
- Yes, Limited a Lot (1)
- Yes, Limited a Little (2)
- No, Not Limited at All (3)
6. Climbing several flights of stairs*
- Yes, Limited a Lot (1)
- Yes, Limited a Little (2)
- No, Not Limited at All (3)
7. Climbing one flight of stairs*
- Yes, Limited a Lot (1)
- Yes, Limited a Little (2)
- No, Not Limited at All (3)
8. Bending, kneeling, or stooping*
- Yes, Limited a Lot (1)
- Yes, Limited a Little (2)
- No, Not Limited at All (3)
9. Walking more than a mile*
- Yes, Limited a Lot (1)
- Yes, Limited a Little (2)
- No, Not Limited at All (3)
10. Walking several blocks*
- Yes, Limited a Lot (1)
- Yes, Limited a Little (2)
- No, Not Limited at All (3)
11. Walking one block*
- Yes, Limited a Lot (1)
- Yes, Limited a Little (2)
- No, Not Limited at All (3)
12. Bathing and dressing yourself*
- Yes, Limited a Lot (1)
- Yes, Limited a Little (2)
- No, Not Limited at All (3)
Role limitations due to physical problems
During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health?
13. Cut down on the amount of time you could spend on work or other activities*
- YES (1)
- NO (2)
14. Accomplished less than you would like*
- YES (1)
- NO (2)
15. Were limited in the kind of work or other activities*
- YES (1)
- NO (2)
16. Had difficulty performing the work or other activities (for example, it took extra effort)*
- YES (1)
- NO (2)
Role limitations due to emotional problems
During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious).
17. Cut down on the amount of time you could spend on work or other activities*
- YES (1)
- NO (2)
18. Accomplished less than you would like*
- YES (1)
- NO (2)
19. Didn't do work or other activities as carefully as usual*
- YES (1)
- NO (2)
20. During the past 4 weeks, to what extent has your physical health or emotional problems interfered with your normal social activities with family, friends, neighbors, or groups?*
- Not at all (1)
- Slightly (2)
- Moderately (3)
- Quite a bit (4)
- Extremely (5)
Pain
21. How much bodily pain have you had during the past 4 weeks?*
- None (1)
- Very Mild (2)
- Mild (3)
- Moderate (4)
- Severe (5)
- Very Severe (5)
22. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)?*
- Not at all (1)
- A little bit (2)
- Moderately (3)
- Quite a bit (4)
- Extremely (5)
Recent Health
These questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling.
23. Did you feel full of pep?*
- All of the Time (1)
- Most of the Time (2)
- A Good Bit of the Time (3)
- Some of the Time (4)
- A Little of the Time (5)
- None of the Time (6)
24. Have you been a very nervous person?*
- All of the Time (1)
- Most of the Time (2)
- A Good Bit of the Time (3)
- Some of the Time (4)
- A Little of the Time (5)
- None of the Time (6)
25. Have you felt so down in the dumps that nothing could cheer you up?*
- All of the Time (1)
- Most of the Time (2)
- A Good Bit of the Time (3)
- Some of the Time (4)
- A Little of the Time (5)
- None of the Time (6)
26. Have you felt calm and peaceful?*
- All of the Time (1)
- Most of the Time (2)
- A Good Bit of the Time (3)
- Some of the Time (4)
- A Little of the Time (5)
- None of the Time (6)
27. Did you have a lot of energy?*
- All of the Time (1)
- Most of the Time (2)
- A Good Bit of the Time (3)
- Some of the Time (4)
- A Little of the Time (5)
- None of the Time (6)
28. Have you felt downhearted and blue?*
- All of the Time (1)
- Most of the Time (2)
- A Good Bit of the Time (3)
- Some of the Time (4)
- A Little of the Time (5)
- None of the Time (6)
29. Did you feel worn out?*
- All of the Time (1)
- Most of the Time (2)
- A Good Bit of the Time (3)
- Some of the Time (4)
- A Little of the Time (5)
- None of the Time (6)
30. Have you been a happy person?*
- All of the Time (1)
- Most of the Time (2)
- A Good Bit of the Time (3)
- Some of the Time (4)
- A Little of the Time (5)
- None of the Time (6)
31. Did you feel tired?*
- All of the Time (1)
- Most of the Time (2)
- A Good Bit of the Time (3)
- Some of the Time (4)
- A Little of the Time (5)
- None of the Time (6)
32. Did you feel rested on waking in the morning?*
- All of the Time (1)
- Most of the Time (2)
- A Good Bit of the Time (3)
- Some of the Time (4)
- A Little of the Time (5)
- None of the Time (6)
33. During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)?*
- All of the time (1)
- Most of the time (2)
- Some of the time (3)
- A little of the time (4)
- None of the time (5)
Health in General
How TRUE or FALSE is each of the following statements for you.
34. I seem to get sick a little easier than other people*
- Definitely True (1)
- Mostly True (2)
- Not Sure (3)
- Mostly False (4)
- Definitely False (5)
35. I am as healthy as anybody I know*
- Definitely True (1)
- Mostly True (2)
- Not Sure (3)
- Mostly False (4)
- Definitely False (5)
36. I expect my health to get worse*
- Definitely True (1)
- Mostly True (2)
- Not Sure (3)
- Mostly False (4)
- Definitely False (5)
37. My health is excellent*
- Definitely True (1)
- Mostly True (2)
- Not Sure (3)
- Mostly False (4)
- Definitely False (5)
Health Distress
How much of the time during the past 4 weeks...
38. Were you discouraged by your health problems?*
- All of the Time (1)
- Most of the Time (2)
- A Good Bit of the Time (3)
- Some of the Time (4)
- A Little of the Time (5)
- None of the Time (6)
39. Were you frustrated about your health?*
- All of the Time (1)
- Most of the Time (2)
- A Good Bit of the Time (3)
- Some of the Time (4)
- A Little of the Time (5)
- None of the Time (6)
40. Was your health a worry in your life?*
- All of the Time (1)
- Most of the Time (2)
- A Good Bit of the Time (3)
- Some of the Time (4)
- A Little of the Time (5)
- None of the Time (6)
41. Did you feel weighed down by your health problems?*
- All of the Time (1)
- Most of the Time (2)
- A Good Bit of the Time (3)
- Some of the Time (4)
- A Little of the Time (5)
- None of the Time (6)
Cognitive Function
How much of the time during the past 4 weeks...
42. Have you had difficulty concentrating and thinking?*
- All of the Time (1)
- Most of the Time (2)
- A Good Bit of the Time (3)
- Some of the Time (4)
- A Little of the Time (5)
- None of the Time (6)
43. Did you have trouble keeping your attention on an activity for long?*
- All of the Time (1)
- Most of the Time (2)
- A Good Bit of the Time (3)
- Some of the Time (4)
- A Little of the Time (5)
- None of the Time (6)
44. Have you had trouble with your memory?*
- All of the Time (1)
- Most of the Time (2)
- A Good Bit of the Time (3)
- Some of the Time (4)
- A Little of the Time (5)
- None of the Time (6)
45. Have others, such as family members or friends, noticed that you have trouble with your memory or problems with your concentration?*
- All of the Time (1)
- Most of the Time (2)
- A Good Bit of the Time (3)
- Some of the Time (4)
- A Little of the Time (5)
- None of the Time (6)
Sexual Function
The next set of questions are about your sexual function and your satisfaction with your sexual function. Please answer as accurately as possible about your function during the last 4 weeks only. How much of a problem was each of the following for you during the past 4 weeks?
46. Lack of sexual interest*
- Not a problem (1)
- A Little of a Problem (2)
- Somewhat of a Problem (3)
- Very Much a Problem (4)
47. Difficulty getting or keeping an erection (Men) or inadequate lubrication (Women)*
- Not a problem (1)
- A Little of a Problem (2)
- Somewhat of a Problem (3)
- Very Much a Problem (4)
48. Difficulty having orgasm*
- Not a problem (1)
- A Little of a Problem (2)
- Somewhat of a Problem (3)
- Very Much a Problem (4)
49. Ability to satisfy sexual partner*
- Not a problem (1)
- A Little of a Problem (2)
- Somewhat of a Problem (3)
- Very Much a Problem (4)
50. Overall, how satisfied were you with your sexual function during the past 4 weeks?*
- Very satisfied (1)
- Somewhat satisfied (2)
- Neither satisfied or dissatisfied (3)
- Somewhat dissatisfied (4)
- Very dissatisfied (5)
Additional Questions
51. During the past 4 weeks, to what extent have problems with your bowel or bladder function interfered with your normal social activities with family, friends, neighbors, or groups?*
- Not at all (1)
- Slightly (2)
- Moderately (3)
- Quite a bit (4)
- Extremely (5)
52. During the past 4 weeks, how much did pain interfere with your enjoyment of life?*
- Not at all (1)
- Slightly (2)
- Moderately (3)
- Quite a bit (4)
- Extremely (5)
53. Overall, based on the scale pictured below, how would you rate your own quality-of-life?*
- 10
- 9
- 8
- 7
- 6
- 5
- 4
- 3
- 2
- 1
- 0
54. Which best describes how you feel about your life as a whole?*
- Terrible (1)
- Unhappy (2)
- Mostly dissatisfied (3)
- Mixed — About equally satisfied and dissatisfied (4)
- Mostly satisfied (5)
- Pleased (6)
- Delighted (7)
Scoring
Physical Health — Score
Role Limitations Due to Physical Problems — Score
Role Limitations Due to Emotional Problems — Score
Pain — Score
Emotional Well-Being — Score
Energy — Score
Health Perceptions — Score
Social Function — Score
Cognitive Function — Score
Health Distress — Score
Sexual Function — Score
Change in Health — Score
Satisfaction With Sexual Function — Score
Overall Quality of Life — Score
MSQOL-54 Physical Health Composite — Score
MSQOL-54 Mental Health Composite — Score
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Multiple Sclerosis Quality of Life Survey (MSQOL-54)

INSTRUCTIONS

General Health

Physical Health

Role limitations due to physical problems

Role limitations due to emotional problems

Pain

Recent Health

Health in General

Health Distress

Cognitive Function

Sexual Function

Additional Questions

Scoring

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