About TCQOLI

[INFORMATION ON THE FORM]

Fertility-Inclusive Questionnaire

Please fill out the items below about health quality of life issues of interest for patients like you.

If you choose to complete the survey before a member of our team calls to interview you, please complete all the questions at the same time.

For the 10 categories below check the one BEST box that describes how you have felt in the PAST SEVEN DAYS.

Not at all A little bit Somewhat Quite a bit Very much
To what extent are you fearful of recurrence of your cancer?
Has your illness or treatment caused negative changes in your appearance?
My illness has been a financial hardship to my family and me.
Changes in my voice have been troubling to me.
Have you had trouble swallowing?
Is your ability to have (more) children a concern for you?
How much did pain interfere with your day-to-day activities?
Never or N/A Rarely Sometimes Often Always
I feel depressed.
How often did you run out of energy?
My thinking has been slow.
“Full Health”
100
90
80
70
60
50
40
30
20
10
0
“Most Disabled”
Your answer: 050