11. How TRUE or FALSE is each of the following statements to you? (Circle one for each line.)
Definitely True
Mostly True
Don’t Know 3
Mostly False
Definitely False
▪ I seem to get sick easier than other people.
1
2
4
5
▪ I am as healthy as anybody I know. ▪ I expect my health to get worse.
1
2
3
4
5
1
2
3
4
5
▪ My health is excellent.
1
2
3
4
5
FACT-G (Version 4) Below is a list of statements that other people with your illness have said are important. Please circle or mark one number per line to indicate your response as it applies to the PAST 7 DAYS. PHYSICAL WELL-BEING
Not at all A little bit Somewhat Quite a bit Very much
I have a lack of energy.
0 0 0 0 0 0 0
1 1 1 1 1 1 1
2 2 2 2 2 2 2
3 3 3 3 3 3 3
4 4 4 4 4 4 4
GP1
I have nausea.
GP2
Because of my physical condition, I have trouble meeting the needs of my family.
GP3
I have pain.
GP4
I am bothered by side effects of treatment.
GP5
I feel ill.
GP6
I am forced to spend time in bed. SOCIAL/FAMILY WELL-BEING
GP7
Not at all A little bit Somewhat Quite a bit Very much
I feel close to my friends.
0 0 0 0 0
1 1 1 1 1
2 2 2 2 2
3 3 3 3 3
4 4 4 4 4
GP1
I get emotional support from my family. I get support from my friends. My family has accepted my illness.
GP2
GP3
GP4
I am satisfied with family communication about my illness. I feel close to my partner (or the person who is my main support). Regardless of your current level of sexual activity, please answer the following question. If you prefer not to answer it, please mark this box and go to the next section.
GP5
0
1
2
3
4
GP6
0
1
2
3
4
Q1
GP7 4 Please circle or mark one number per line to indicate your response as it applies to the PAST 7 DAYS. EMOTIONAL WELL-BEING Not at all A little bit Somewhat Quite a bit Very much GP1 I feel sad. 0 1 2 3 4 GP2 I am satisfied with how I am coping with my illness. 0 1 2 3 4 GP3 I am losing hope in the fight against my illness. 0 1 2 3 4 GP4 I feel nervous. 0 1 2 3 4 GP5 I worry about dying. 0 1 2 3 4 GP6 I worry that my condition will get worse. 0 1 2 3 4 FUNCTIONAL WELL-BEING Not at all A little bit Somewhat Quite a bit Very much GP1 I am able to work (include work at home). 0 1 2 3 4 GP2 My work (include work at home) is fulfilling. 0 1 2 3 4 GP3 I am able to enjoy life. 0 1 2 3 4 GP4 I have accepted my illness. 0 1 2 3 4 GP5 I am sleeping well. 0 1 2 3 4 GP6 I am enjoying the things I usually do for fun. 0 1 2 3 4 GP7 I am content with the quality of my life right now. 0 1 2 3 4 I am satisfied with my sex life. 0 1 2 3
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