Cancer Functional Living Index Questionnaire Form
Please answer the following questions to help us understand how cancer is affecting your daily living. Your responses are important for assessing functional well-being.
How would you rate your overall physical well-being over the past week?
*
1
2
3
4
5
How much difficulty have you had performing your usual daily activities?
*
No difficulty
1
2
3
4
Extreme difficulty
5
1 is No difficulty, 5 is Extreme difficulty
During the past week, how often did pain interfere with your daily life?
*
Never
Rarely
Sometimes
Often
Always
How would you rate your ability to perform self-care activities (such as bathing or dressing)?
*
1
2
3
4
5
How much support do you feel you have from family or friends?
*
None
A little
Some
Quite a bit
A lot
How would you rate your energy level in the past week?
*
Very low
1
2
3
4
Very high
5
1 is Very low, 5 is Very high
How often have you felt anxious or worried because of your health?
*
Never
Rarely
Sometimes
Often
Always
How would you rate your ability to enjoy social activities?
*
1
2
3
4
5
How much has your appetite changed in the past week?
*
No change
Slight decrease
Moderate decrease
Severe decrease
Increase
Please share any additional comments about how cancer has affected your daily living.
Submit
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