FACT-MM20 Quality of Life Assessment Questionnaire
Complete this quality of life assessment using the same title throughout the form. The form uses a polished, minimal SaaS style and is intended for assessment purposes only.
Assessment Overview
Role or relationship to the person being assessed
*
Self
Caregiver
Clinician
Other
Assessment period or reference timeframe
Quality of Life Ratings
Quality of Life Domain Ratings
*
Rows
0 - Not at all
1 - A little
2 - Somewhat
3 - Quite a bit
4 - Very much
Physical well-being
1
2
3
4
5
Emotional well-being
6
7
8
9
10
Social/family well-being
11
12
13
14
15
Functional well-being
16
17
18
19
20
Symptom impact
21
22
23
24
25
Overall quality of life today
*
Poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Poor, 10 is Excellent
Which area is affected the most right now?
Please Select
Physical well-being
Emotional well-being
Social/family well-being
Functional well-being
Symptom impact
All equally
None of these
Briefly describe any major factors affecting your quality of life
Symptom and Impact Details
Overall symptom severity
*
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
How much do symptoms interfere with daily activities?
*
Not at all
1
2
3
4
5
6
7
8
9
Extremely
10
1 is Not at all, 10 is Extremely
Submit
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