Your responses will be reviewed by a clinical research associate at McMaster University's Division of Gastroenterology and an individualized report will be e-mailed to you within 1 business day.

Your responses will be kept strictly confidential and used for research purposes only, so please be as accurate as possible. The QOLRAD (Quality of Life in Reflux and Dyspepsia) survey is composed of 25 questions and should take about 5 minutes to complete. Complete this survey monthly to re-evaluate your score.

   
 
 
 
 
     
     
       
     
         
           
Demographics
 
What is your date of birth?
   
What is your gender? male female
   
In what country do you live?
   
In what state/ province do you live? (US and CDN residents)
 
Which of these symptoms is your MAIN gastrointestinal complaint?
Upper abdominal pain (pain above the navel/ stomach pain)
Nausea or vomiting or abdominal bloating with visible distention (noticeably swollen belly)
Heartburn (pain or burning radiating up to the throat) or acid regurgitation (sour taste/ stomach contents coming back up
I don't have any of these symptoms
 
Has your doctor EVER told you that you have ANY of the following?
PLEASE CHECK ALL THAT APPLY.
Gastro-esophageal reflux disease (GERD) or Reflux
Gastritis (stomach inflammation) Esophagitis
Dyspepsia (indigestion) Peptic ulcer disease (Ulcers)
Helicobacter pylori infection Chronic cough
Gallstones Pancreatitis
Lactose intolerance Celiac disease
Stomach cancer Irritable bowel syndrome (IBS)
Dysmotility (motility disorder) other:
My gastrointestinal symptoms have not yet been diagnosed
I have not seen a doctor about my symptoms
Quality of Life in Reflux and Dyspepsia (QoLRAD)
THINK BACK OVER THE PAST 4 WEEKS. Please read this carefully BEFORE ANSWERING THE QUESTIONS. On the following pages you will find some questions asking about how you have been feeling because of symptoms of STOMACH PROBLEMS (your upper gastrointestinal symptoms). Please answer all of these questions as honestly as you can. For each question, tick the box that best describes how you have been feeling DURING THE PAST 4 WEEKS.
1. How often during the past 4 weeks have you been FEELING TIRED OR WORN OUT BECAUSE OF STOMACH PROBLEMS?
All of the time
Most of the time
Quite a lot of the time
Some of the time
A little of the time
Hardly any of the time
None of the time
2. How often during the past 4 weeks did you AVOID BENDING OVER BECAUSE OF STOMACH PROBLEMS?
All of the time
Most of the time
Quite a lot of the time
Some of the time
A little of the time
Hardly any of the time
None of the time
 
3. During the past 4 weeks, did you have STOMACH PROBLEMS BECAUSE OF EATING OR DRINKING?
A great deal
A lot
A moderate amount
To some extent
A little
Hardly at all
Not at all
4. How often during the past 4 weeks have you FELT GENERALLY UNWELL BECAUSE OF STOMACH PROBLEMS?
All of the time
Most of the time
Quite a lot of the time
Some of the time
A little of the time
Hardly any of the time
None of the time
5. How often during the past 4 weeks was it NECESSARY TO EAT LESS THAN USUAL BECAUSE OF STOMACH PROBLEMS?
All of the time
Most of the time
Quite a lot of the time
Some of the time
A little of the time
Hardly any of the time
None of the time
 
6. How often during the past 4 weeks have STOMACH PROBLEMS KEPT YOU FROM DOING THINGS WITH FAMILY OR FRIENDS?
All of the time
Most of the time
Quite a lot of the time
Some of the time
A little of the time
Hardly any of the time
None of the time
7. How often during the past 4 weeks did you have A LACK OF ENERGY BECAUSE OF STOMACH PROBLEMS?
All of the time
Most of the time
Quite a lot of the time
Some of the time
A little of the time
Hardly any of the time
None of the time
 
8. How often during the past 4 weeks have you had DIFFICULTY GETTING A GOOD NIGHT'S SLEEP because of stomach problems?
All of the time
Most of the time
Quite a lot of the time
Some of the time
A little of the time
Hardly any of the time
None of the time
9. How often during the past 4 weeks have stomac problems MADE IT DIFFICULT TO EAT THE FOODS OR SNACKS YOU LIKE?
All of the time
Most of the time
Quite a lot of the time
Some of the time
A little of the time
Hardly any of the time
None of the time
 
10. How often during the past 4 weeks did you FEEL TIRED OR WORN OUT DUE TO LACK OF SLEEP BECAUSE OF STOMACH PROBLEMS?
All of the time
Most of the time
Quite a lot of the time
Some of the time
A little of the time
Hardly any of the time
None of the time
 
11. How often during the past 4 weeks did STOMACH PROBLEMS WAKE YOU UP AT NIGHT AND PREVENT YOU FROM FALLING ASLEEP AGAIN?
All of the time
Most of the time
Quite a lot of the time
Some of the time
A little of the time
Hardly any of the time
None of the time
 
12. How often during the past 4 weeks have you felt DISCOURAGED OR DISTRESSED BECAUSE OF STOMACH PROBLEMS?
All of the time
Most of the time
Quite a lot of the time
Some of the time
A little of the time
Hardly any of the time
None of the time
 
13. How often during the past 4 weeks have STOMACH PROBLEMS MADE FOOD SEEM UNAPPEALING TO YOU?
All of the time
Most of the time
Quite a lot of the time
Some of the time
A little of the time
Hardly any of the time
None of the time
 
14. How often during the past 4 weeks have you FELT FRUSTRATED OR IMPATIENT BECAUSE OF STOMACH PROBLEMS?
All of the time
Most of the time
Quite a lot of the time
Some of the time
A little of the time
Hardly any of the time
None of the time
 
15. How often during the past 4 weeks have you been ANXIOUS OR UPSET BECAUSE OF STOMACH PROBLEMS?
All of the time
Most of the time
Quite a lot of the time
Some of the time
A little of the time
Hardly any of the time
None of the time
 
16. During the past 4 weeks, have you had STOMACH PROBLEMS BECAUSE OF EATING FOODS OR SNACKS YOU COULD NOT TOLERATE?
A great deal
A lot
A moderate amount
To some extent
A little
Hardly at all
Not at all
 
17. How often during the past 4 weeks have you had WORRIES OR FEARS ABOUT YOUR HEALTH BECAUSE OF STOMACH PROBLEMS?
All of the time
Most of the time
Quite a lot of the time
Some of the time
A little of the time
Hardly any of the time
None of the time
 
18. How often during the past 4 weeks did you FAIL TO WAKE UP IN THE MORNING FEELING FRESH AND RESTED BECAUSE OF STOMACH PROBLEMS?
All of the time
Most of the time
Quite a lot of the time
Some of the time
A little of the time
Hardly any of the time
None of the time
 
19. How much during the past 4 weeks have STOMACH PROBLEMS MADE YOU FEEL IRRITABLE?
A great deal
A lot
A moderate amount
To some extent
A little
Hardly at all
Not at all
 
20. How often during the past 4 weeks have you had to AVOID CERTAIN FOOD, BEVERAGES OR DRINKS BECAUSE OF STOMACH PROBLEMS?
All of the time
Most of the time
Quite a lot of the time
Some of the time
A little of the time
Hardly any of the time
None of the time
 
21. How often during the past 4 weeks did you HAVE TROUBLE GETTING TO SLEEP BECAUSE OF STOMACH PROBLEMS?
All of the time
Most of the time
Quite a lot of the time
Some of the time
A little of the time
Hardly any of the time
None of the time
 
22. How often during the past 4 weeks did you FEEL FRUSTRATED BECAUSE THE EXACT CAUSE OF YOUR SYMPTOMS IS NOT KNOWN AND YOU STILL HAVE SO MUCH STOMACH PROBLEMS?
All of the time
Most of the time
Quite a lot of the time
Some of the time
A little of the time
Hardly any of the time
None of the time
 
23. How often during the past 4 weeks did you have DIFFICULTY SOCIALIZING WITH FAMILY OR FRIENDS BECAUSE OF STOMACH PROBLEMS?
All of the time
Most of the time
Quite a lot of the time
Some of the time
A little of the time
Hardly any of the time
None of the time
 
24. How often during the past 4 weeks were you UNABLE TO CARRY OUT YOUR DAILY ACTIVITIES (INCLUDING BOTH WORK OUTSIDE THE HOME AND HOUSE WORK) DUE TO STOMACH PROBLEMS?
All of the time
Most of the time
Quite a lot of the time
Some of the time
A little of the time
Hardly any of the time
None of the time
 
25. How often during the past 4 weeks were you UNABLE TO CARRY OUT YOUR NORMAL PHYSICAL ACTIVITIES (INCLUDING SPORT, LEISURE ACTIVITIES AND MOVING AROUND OUTSIDE THE HOME) DUE TO STOMACH PROBLEMS?
All of the time
Most of the time
Quite a lot of the time
Some of the time
A little of the time
Hardly any of the time
None of the time
 
To receive your individualized report please provide a contact e-mail address.
 
e-mail address:
 



     
Copyright 2001-2002, mydyspepsia.com. All rights reserverd.