Japanese Osteoporosis Quality of Life Questionnaire

Appendix

Japanese Society for Bone and Mineral Research

Committee of Evaluation of Quality of Life for Osteoporotic Patients

Note :

On occasion in inquiring quality of life with JOQOL:

This questionnaire is for those who can take meals and can walk either indoors or outdoors by themselves. However, it does not matter whether they need help (assistance) or any tools for walking ( a cane, a handcart, etc), while walking.

This questionnaire consists of inquiry sheet on present status (to be filled by a respondent), questionnaire sheet for evaluation (to be filled by a respondent), and result sheet of measurements (to be filled by a doctor or an inquirer).

Please, fill out inquiry sheet on present status and questionnaire sheet for evaluation by a respondent, if possible. But, if not, please, fill out by his or her a family member or a supporter.

Questionnaire sheet for evaluation

( Please, select an answer in the following questions.)

Pain

The following five questions in this section are asking you about your situation in the last week. Please, select an answer in each question circling it.

How often have you had back or low back pain in the last week ?

1)Never

2)1 day per week or less

3)2-3 days per week

4)4-6 days per week

5)Every day

If you have had back pain or low back pain, for how long did you have it in the daytime ?

1)No pain

2)1-2 hours

3)3-5 hours

4)6-10 hours

5)All day

While you kept still, how severe was your back or low back pain ?

1)No pain

2)Mild

3)Moderate

4)Severe

5)Unbearable

When you moved, how severe was your back or low back pain ?

1)No pain

2)Mild

3)Moderate

4)Severe

5)Unbearable

5. Has the back or low back pain disturbed your sleep in the last week ?

1) Never

2) Once

3) Twice

4) Every other night

5) Almost every njght

This Section Asks about Your Activities of Daily Living.

Self-Care Tasks

The next four questions regard your situation at present. For each question, choose one, answer and circle it.

6. Do you have problems with dressing?

1) no difficulty

2) a little difficulty

3) moderate difficulty

4) may need some help (assistance)

5) impossible without help (assistance)

7. Do you have problems with getting to or operating a toilet?

1) no difficulty

2) a little difficulty

3) moderate difficulty

4) may need some help (assistance)

5) impossible without help (assistance)

8. When you moved the bowels, do you have problems with using a Japanese-style toilet?

1) no difficulty

2) a little difficulty

3) impossible. Only with a Western-style

9. Do you have problems with taking a bath?

1) without difficulty

2) with a little difficulty

3) with moderate difficulty

4) with some help (assistance)

5) impossible without help (assistance)

Housework

The next 5 questions are concerned with the present situation. If someone else does these things in your house, please answer as though you were responsible for them.

10. Can you prepare meals?

1) without difficulty

2) with a little difficulty

3) with moderate difficulty

4) with some help (assistance)

5) impossible without help (assistance)

11. Can you do the cleaning?

1) without difficulty

2) with a little difficulty

3) with moderate difficulty

4) with some help (assistance)

5) impossible without help (assistance)

12. Can you take things on shelves above your head, extending your hand?_

1) without difficulty

2) with a little difficulty

3) with moderate difficulty

4) possible to touch them, but impossible to take them

5) hard to raise a hand, and impossible to take them

13. Can you go shopping for daily necessities (foods, etc.) by yourself?

1) without difficulty

2) with a little difficulty

3) with moderate difficulty

4) with some help (assistance)

5) impossible

14. Can you carry a heavy object of 5 kg (e.g., 2 bottles of one sho, 1.8 liter of Sake, Japanese rice wine, or 2 bottles of 2 liter-contained PET bottles) for at least 10 meters?

1) 5 kg ( 2 bottles ) without difficulty

2) 5 kg ( 2 bottles ) with a little difficulty

3) 2.5 kg ( 1 bottle ) without difficulty

4) 2.5 kg (1 bottle ) with a little difficulty

5) impossible to carry an object of 2.5 kg ( 1 bottle )

Transfer

The following 7 questions regard also the present situation. Please, answer whether you can do it. On each question, choose one answer and circle it.

15. Can you get up from a chair?

1) without difficulty

2) with a little difficulty

3) with moderate difficulty

4) with a little help (assistance)

5) only with help (assistance)

16. Can you stand up from a tatami mat (floor)?

1) without difficulty

2) with a little difficulty

3) with moderate difficulty

4) with a little help (assistance)

5) only with help (assistance)

17. Can you bend down and touch the floor, while standing?

1) easily down to the floor with the palm

2) down to the floor with the fingertip

3) down to foot or leg below the knee with the fingertip

4) down to knee or thigh with the fingertip

5) impossible to bend down while standing

18. Can you continuously walk longer than 50 meters?

1) fast without stopping

2) slowly without stopping

3) slowly with at least one stop

4) only with help (assistance)(including a cane, a handcart, etc.)

5) impossible

19. Do you use a cane, while walking outside?

1) never

2) rarely

3) sometimes

4) almost

5) always

20. Can you climb up and down stairs to the next floor of a house?

1) without difficulty

2) without difficulty as holding a handrail

3) with moderate difficulty as holding a handrail

4) with help (assistance) only

5) impossible

21. Can you use public transport such as a bus or a train (excluding your own car or taxi)?

1) without difficulty

2) with a little difficulty

3) with moderate difficulty

4) with a companion

5) impossible

Leisure, Social Activities

For each question, choose one answer and circle it.

22. How often have you been outside in the last week?

1) Everyday

2) 5-6 days

3) 3-4 days

4) 1-2 days

5) Never

23. How often did you visit your friend or relatives at their homes during the last three months?_

1) Once a week and more

2) Once or twice a month

3) Less than once a month

4) Never

24. How often did you participate in local events such as festivals or meetings during the last three months?

1) Once a week and more

2) Once or twice a month

3) Less than once a month

4) Never

25. How often did you go traveling or enjoy a leisure-trip in the last three months?

1) Once a week and more

2) Once or twice a month

3) Less than once a month

4) Never

26. How often did you work in the garden, participate in the gate-ball, etc. during the last three months?

1) yes

2) a little

3) not at all

Genaral Health Perception

The following questions regard the present condition of your health.

For each question, choose one answer and circle it.

27. For your age, in general, would you say your health is

1) excellent

2) good

3) satisfactory

4) fair

5) poor

28. How would you rate your present health compared with a year ago?

1) much better now

2) slightly better now

3) unchanged

4) slightly worse now

5) much worse now

29. Do you satisfy your present life compared with a year ago?

1) much better now

2) slightly better now

3) unchanged

4) slightly worse now

5) much worse now

Posture and Figure

The following 4 questions regard your present posture and figure. In the question 30 and 31, choose an answer and circle it.

30. Are you shorter in height than 10 years ago?

1) unchanged

2) slightly

3) moderately

4) considerably

5) extremely

31. Do your back get hunched-up compared with 10 years ago?

1) unchanged

2) slightly

3) moderately

4) considerably

5) extremely

The following two questions (32 and 33) are for those the figure have changed (loss of height and hunched back). Choose an answer and circle it.

If unchanged, skip question 32 and 33.

32. Do you worry about your figure changed?

1) always

2) often

3) sometimes

4) rarely

5) never

33. This question is for those with hunched-back. Do you have any symptoms listed below. Choose all answers that you have, and circle them.

1) shortness of breath

2) heartburn

3) bloated

4) constipation

5) loss of appetite

6) no symptoms listed above

Fear of falling and mental factors

The following four questions regard the situation in the last two weeks. Choose an answer and circle it.

34. Have you felt fear of falling?

1) always

2) often

3) sometimes

4) rarely

5) never

35. Have you given up what you wanted to do due to fear of falling?

1) always

2) often

3) sometimes

4) rarely

5) never

36. Have you felt refreshed, when you woke up in the morning?

1) always

2) often

3) sometimes

4) rarely

5) never

37. Have you been bothered with your nevousness?

1) always

2) often

3) sometimes

4) rarely

5) never

38. Are you afraid of becoming totally dependent on your family of friends?

1) never

2) rarely

3) sometimes

4) often

5) always

* If you are diagnosed as osteoporosis, please answer this question.

Which troubles listed below do you have when you have osteoporosis?

Choose three answers or less that apply to you, and give them in order of troublesome.

1)back or low back pain

2)inconvenience for self-care task or housework

3)pain of the body while long standing

4)difficulty of social activities with neighbors, outing or traveling

5)loss of height and poor posture

6)being nervous or getting irritated

7)fear of falling or having fracture

8)fear of being bedridden

9)no troubles so far

Please, fill out numbers in order of troublesome.

①　＿＿＿＿＿＿＿＿ ②　＿＿＿＿＿＿＿＿＿ ③＿＿＿＿＿＿＿＿＿＿