Non-Fertility Questionnaire

Please fill out the items below about health quality-of-life issues relevant to thyroid cancer. Select one option per row reflecting how you have felt in the past seven days.

For the 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?
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