Quality of Life Questionnaire in Gastroesophageal Reflux Questionnaire developed by laboratoires Houdé, Mapi, M. Amouretti, J.P. Galmiche, T. Poynard 1
How to complete the questionnaire The following questions are about your health during the past 4 weeks. Please answer all questions by circling only one number per question. Choose the response that best describes how you feel or how you have felt during the past 4 weeks. Example: During the past 4 weeks, because of your digestive problems, have you been bothered by stomach pains? Not applicable 1 2 4 5 0 Please, answer every question even if some of them seem similar to you. If you do not participate in certain activities (ex: sports, gardening,...) circle 0 for "Not applicable". If you make a mistake, please cross out the wrong answer and circle the one that best applies to you. We would like you to try to answer this questionnaire on your own. Thank you for your participation. Questionnaire developed by laboratoires Houdé, Mapi, M. Amouretti, J.P. Galmiche, T. Poynard 2
Daily life 1. During the past 4 weeks, because of your digestive problems, have you felt uncomfortable when bending down to put your shoes or socks on? 2. During the past 4 weeks, because of your digestive problems, have you had difficulty doing things that needed to be done with as much attention as usual? 3. During the past 4 weeks, because of your digestive problems, have you done less than usual? 4. During the past 4 weeks, have you consciously avoided movements that might have made your digestive problems worse? 5. During the past 4 weeks, have you been bothered by your digestive problems when gardening, doing odd jobs or doing housework? Not applicable 0 6. During the past 4 weeks, have you been bothered by your digestive problems when wearing tight clothes? Not applicable 0 Questionnaire developed by laboratoires Houdé, Mapi, M. Amouretti, J.P. Galmiche, T. Poynard 3
Relationships 7. During the past 4 weeks, have you felt embarrassed because of your digestive problems when having meals with others? 8. During the past 4 weeks, have you felt embarrassed because of your digestive problems at times other than during meals? Questionnaire developed by laboratoires Houdé, Mapi, M. Amouretti, J.P. Galmiche, T. Poynard 4
Quality of life 9. During the past 4 weeks, have you been able to lead a relatively normal life even though you have digestive problems? 10. During the past 4 weeks, have you felt satisfied with your life in general even though you have digestive problems? 11. During the past 4 weeks, have you felt tired because of your digestive problems? 12. During the past 4 weeks, have you felt exhausted because of your digestive problems? 13. During the past 4 weeks, have you felt good about yourself even though you have digestive problems? 14. During the past 4 weeks, because of your digestive problems, have you felt like not performing certain activities or doing certain things? Questionnaire developed by laboratoires Houdé, Mapi, M. Amouretti, J.P. Galmiche, T. Poynard 5
15. During the past 4 weeks, considering your digestive problems, have you enjoyed your favorite leisure activities? 16. During the past 4 weeks, considering your digestive problems, have you enjoyed food? Questionnaire developed by laboratoires Houdé, Mapi, M. Amouretti, J.P. Galmiche, T. Poynard 6
State of mind 17. During the past 4 weeks, have you been worried because of your digestive problems? 18. During the past 4 weeks, have your digestive problems disturbed your quality of life? 19. During the past 4 weeks, have you felt obsessed with your digestive problems? 20. During the past 4 weeks, because of your digestive problems, have you been irritated? 21. During the past 4 weeks, because of your digestive problems, have you been in a bad mood? 22. During the past 4 weeks, have you felt as if your digestive problems were a handicap? 23. During the past 4 weeks, have your digestive problems been a source of discomfort? Questionnaire developed by laboratoires Houdé, Mapi, M. Amouretti, J.P. Galmiche, T. Poynard 7
Worries and concerns 24. Are you worried that you won't find a solution to your digestive problems? 25. Are you worried your digestive problems will get worse? 26. Are you worried that you have a serious illness? 27. Are you worried you will need an operation for your digestive problems? 28. Are you worried that your treatment is no longer effective? Questionnaire developed by laboratoires Houdé, Mapi, M. Amouretti, J.P. Galmiche, T. Poynard 8
Sleep 29. During the past 4 weeks, considering your digestive problems, have you felt you have had enough sleep? 30. During the past 4 weeks, because of your digestive problems, have you felt anxious about going to bed? 31. During the past 4 weeks, did your digestive problems wake you up from sleep? 32. During the past 4 weeks, have your digestive problems kept you awake most of the night? 33. During the past 4 weeks, when your digestive problems woke you up, did you have difficulty getting back to sleep? Not applicable 0 Questionnaire developed by laboratoires Houdé, Mapi, M. Amouretti, J.P. Galmiche, T. Poynard 9
Food 34. During the past 4 weeks, after eating, have you had to wait a while before going to bed? 35. During the past 4 weeks, have you had to eat small meals to avoid having digestive problems? 36. During the past 4 weeks, have you avoided eating large meals because you were afraid of having digestive problems? 37. During the past 4 weeks, have your digestive problems been triggered by eating a meal (even a small one) in a stressful or busy environment? Questionnaire developed by laboratoires Houdé, Mapi, M. Amouretti, J.P. Galmiche, T. Poynard 10