Additional Concern | Not at all | A little bit | Some- what | Quite a bit | Very much | Â | Â | Â | Â | Â | |
---|---|---|---|---|---|---|---|---|---|---|---|
35. | I am losing weight....................................... | 0 | 1 | 2 | 3 | 4 | Â | Â | Â | Â | Â |
36. | I have a good appetite................................... | 0 | 1 | 2 | 3 | 4 | Â | Â | Â | Â | Â |
37. | I have aches and pains that bother me | 0 | 1 | 2 | 3 | 4 | Â | Â | Â | Â | Â |
38. | I have certain areas of my body where I experience significant pain | 0 | 1 | 2 | 3 | 4 | Â | Â | Â | Â | Â |
39. | My pain keeps me from doing things I want to do... | 0 | 1 | 2 | 3 | 4 | Â | Â | Â | Â | Â |
40. | I am satisfied with my present comfort level.......... | 0 | 1 | 2 | 3 | 4 | Â | Â | Â | Â | Â |
41. | I am able to feel like a man.............................. | 0 | 1 | 2 | 3 | 4 | Â | Â | Â | Â | Â |
42. | I have trouble moving my bowels..................... | 0 | 1 | 2 | 3 | 4 | Â | Â | Â | Â | Â |
43. | I have difficulty urinating....................................... | 0 | 1 | 2 | 3 | 4 | Â | Â | Â | Â | Â |
44. | I urinate more frequently than usual................... | 0 | 1 | 2 | 3 | 4 | Â | Â | Â | Â | Â |
44. | I have difficulty starting to urinate...................... | 0 | 1 | 2 | 3 | 4 | Â | Â | Â | Â | Â |
45. | My problems with urinating limit my activities...... | 0 | 1 | 2 | 3 | 4 | Â | Â | Â | Â | Â |
46 | I am able to have and keep an erection | 0 | 1 | 2 | 3 | 4 | Â | Â | Â | Â | Â |
47. | I have rectal bleeding.................................... | 0 | 1 | 2 | 3 | 4 | Â | Â | Â | Â | Â |
48. | I have diarrhea............................................. | 0 | 1 | 2 | 3 | 4 | Â | Â | Â | Â | Â |
49. | I have blood in my urine................................. | 0 | 1 | 2 | 3 | 4 | Â | Â | Â | Â | Â |
50. | Looking at the above 15 questions, how much would you say these ADDITIONAL CONCERNS affect your quality of life? (circle one number) | ||||||||||
 | 0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 |
 | Not at all |  |  |  |  |  |  |  | Very much so |