IO Survivor Questionnaire

Explainer Video

Birthdate

Date

Sex

Race or ethnic group

Eircode

1. Do you have any trouble doing strenuous activities, like carrying a heavy shopping bag or a suitcase?

2. Do you have any trouble taking a long walk?Type a question

3. Do you have any trouble taking a short walk outside of the house?

4. Do you need to stay in bed or a chair during the day?

1

2

3

4

1 is Not at all, 4 is Very Much

5. Do you need help with eating, dressing, washing yourself or using the toilet?

1

2

3

4

1 is Not at all, 4 is Very Much

6. Were you limited in doing either your work or other daily activities?

7. Were you limited in pursuing your hobbies or other leisure time activities?

8. Have you had difficulty in concentrating on things, like reading a newspaper or watching television?

9. Did you feel tense?

10. Did you worry?

11. Did you feel irritable?

12. Did you feel depressed?

13. Have you had difficulty remembering things?

14. Has your physical condition or medical treatment interfered with your family life?

15. Has your physical condition or medical treatment interfered with your social activities?

16. How would you rate your overall health during the past week?

17. How would you rate your overall quality of life during the past week?

1. Have you had chills?

2. Have you lost any hair?

3. Have you had a dry mouth?

4. Have you felt that your ability to think, to process information, has slowed down?

5. Have you had a rash?

6. Have you felt drowsy?

7. Have you had problems with your eyes, for example burning, watery, irritated or dry?

8. When you felt the urge to pass urine, did you have to hurry to get to the toilet?

9. Have you had trouble finding the right words to express yourself?

10. Have you had headaches?

11. Have you had unintentional release of gas or flatulence from your back passage?

12. Have you felt ill or unwell?

13. Have you bruised easily?

14. Have food and drink tasted different from usual?

15. Have you had aches or pains in your muscles?

16. Have you had swelling in any part of your body, for example ankles, legs, arms, hands or fingers?

17. Have you had muscle weakness?

18. Have you had problems tolerating heat or cold?

19. Have you had aches or pains in your bones?

20. Have you had itching?

21. Have you had to urinate frequently?

22. Has your skin been more sensitive to the sun?

23. Have you had problems thinking clearly?

24. Have you had stiffness in your joints?

25. Have you had palpitations, faster or irregular heartbeat?

26. Have you had mood swings?

27. Have you had tingling or numbness in your hands or feet?

28. Have you had pain in your chest?

29. Have you had skin problems, for example itchy, dry, flaky?

30. Have you felt thirsty?

1. I know that I have enough money in savings, retirement, or assets to cover the costs of my treatment.

2. My out-of-pocket medical expenses are more than I thought they would be.

3. I worry about the financial problems I will have in the future as a result of my illness or treatment.

4. I feel I have no choice about the amount of money I spend on care.

5. I am frustrated that I cannot work or contribute as much as I usually do.

6. I am satisfied with my current financial situation.

7. I am able to meet my monthly expenses.

8. I feel financially stressed.

9. I am concerned about keeping my job and income, including paid work at home.

10. My cancer or treatment has reduced my satisfaction with my present financial situation.

11. I feel in control of my financial situation.

12. My illness has been a financial hardship to my family and me.

IO Survivor Questionnaire

Demographics

EORTC QLQ-F17

EORTC IL453

Financial toxicity FT1–FT12