AnyQuest for Windows Questionnaire Definition File Version 2.36_4 X$d4 /bK,"Arialne# West"Arialne# West"ArialneD West"ArialneD West"Arial d?"ArialneD West"ArialneD West"Arial d?"Arial d?"Arialne# West_\_d_,.1Minnesota Living with Heart Failure QuestionnaireMLHFQEnglishQDW Version 1.14Bx`Bxp4 X,uX* Dear Patient,Neue Erklaerung Teil 2_d4NkdThe following questions concern how your heart failure (heart condition) has prevented you from living as you wanted during the last month. The items shown later describe different ways some people are affected. If you are sure an item does not apply to you or is not related to your heart failure, then check "No". If an item does apply to you, then check the answer field rating how much it prevented you from living as you wanted.1,00 ?5K ?5Bd ?5 X,uX*+...causing swelling your ankles, legs, etc?WDid your heart failure prevent you from living as you wanted during the last month by:Neue Erklaerung Teil 2p ?5&t ?5DbdNo0 ?5& ?5Nbd Very little1`d ?5b-d2%l ?5Ybd3lt ?5b7d4 ?50& ?5dbd Very much5?5o$?5,Y2%I do not want to answer this question7,00?5oFd?5,?Yk2I cannot answer this question7,00?5KH?5B?5 X,uX*6...making you sit or lie down to rest during the day?WDid your heart failure prevent you from living as you wanted during the last month by:Neue Erklaerung Teil 20?5&4?5DbdNo0?5&?5Nbd Very little1`?5b-d2%?5Ybd3l?5b7d4?50&?5dbd Very much5?5o,?5,Y2%I do not want to answer this question7,00?5oFd<?5,?Yk2I cannot answer this question7,007Kp7B7 X,uX*;...making your walking about or climbing stairs difficult?WDid your heart failure prevent you from living as you wanted during the last month by:Neue Erklaerung Teil 27&7DbdNo07&7Nbd Very little1`7b-d2%47Ybd3l<7b7d4P70&7dbd Very much57o7,Y2%I do not want to answer this question7,00l7oFd7,?Yk2I cannot answer this question7,00\ 7K7B7 X,uX*;...making your working around the house or yard difficult?WDid your heart failure prevent you from living as you wanted during the last month by:Neue Erklaerung Teil 27&7DbdNo07&<7Nbd Very little1`7b-d2%@ 7Ybd3lH 7b7d4 70&P 7dbd Very much5,7o 7,Y2%I do not want to answer this question7,008 7oFdt 7,?Yk2I cannot answer this question7,005K5B(5 X,uX*6...making your going places away from home difficult?WDid your heart failure prevent you from living as you wanted during the last month by:Neue Erklaerung Teil 2@5&D5DbdNo0h5&x5Nbd Very little1`5b-d2%5Ybd3l`5b7d450&5dbd Very much55o5,Y2%I do not want to answer this question7,00P5oFdd5,?Yk2I cannot answer this question7,005K4 5B5 X,uX*1...making your sleeping well at night difficult?WDid your heart failure prevent you from living as you wanted during the last month by:Neue Erklaerung Teil 25&5DbdNo05&5Nbd Very little1`\5b-d2%5Ybd3l<5b7d4P50&\5dbd Very much5 5oh5,Y2%I do not want to answer this question7,00|5oFd@ 5,?Yk2I cannot answer this question7,005K5B 5 X,uX*R...making your relating to or doing things with your friends or family difficult?WDid your heart failure prevent you from living as you wanted during the last month by:Neue Erklaerung Teil 2 5& 5DbdNo0 5& 5Nbd Very little1`\ 5b-d2%T 5Ybd3l\ 5b7d450& 5dbd Very much55o5,Y2%I do not want to answer this question7,00l5oFd5,?Yk2I cannot answer this question7,005K85B5 X,uX*3...making your working to earn a living difficult?WDid your heart failure prevent you from living as you wanted during the last month by:Neue Erklaerung Teil 285&H5DbdNo05&d5Nbd Very little1`\5b-d2%5Ybd3l5b7d450&5dbd Very much5(5oX5,Y2%I do not want to answer this question7,005oFd5,?Yk2I cannot answer this question7,00/7K/7Bp/7 X,uX*C...making your recreational pastimes, sports or hobbies difficult?WDid your heart failure prevent you from living as you wanted during the last month by:Neue Erklaerung Teil 2(/7&,/7DbdNo0 /7&4/7Nbd Very little1` /7b-d2% /7Ybd3l /7b7d4/70& /7dbd Very much5 /7o/7,Y2%I do not want to answer this question7,00/7oFd/7,?Yk2I cannot answer this question7,00K Bd X,uX*+...making your sexual activities difficult?WDid your heart failure prevent you from living as you wanted during the last month by:Neue Erklaerung Teil 2&DbdNo00&@Nbd Very little1`Hb-d2% Ybd3lb7d4(0& dbd Very much5@o ,Y2%I do not want to answer this question7,00 oFdx,?Yk2I cannot answer this question7,00 *K|*B* X,uX*....making you eat less of the foods you like?WDid your heart failure prevent you from living as you wanted during the last month by:Neue Erklaerung Teil 2D*&H*DbdNo0*&*Nbd Very little1`*b-d2%,*Ybd3l4*b7d4H*0&T*dbd Very much5*o*,Y2%I do not want to answer this question7,008*oFd*,?Yk2I cannot answer this question7,00h4K`4BX4 X ,uX*...making you short of breath?WDid your heart failure prevent you from living as you wanted during the last month by:Neue Erklaerung Teil 2t4&< 4DbdNo04& 4Nbd Very little1` b-d2%Ybd3lb7d40&dbd Very much5x o,Y2%I do not want to answer this question7,00<oFd,?Yk2I cannot answer this question7,00 7KH7B@7 X ,uX*1...making you tired, fatigued, or low on energy?WDid your heart failure prevent you from living as you wanted during the last month by:Neue Erklaerung Teil 2l7&7DbdNo07&7Nbd Very little1`7b-d2% 7Ybd3l W b7d4`W 0&lW dbd Very much5<8o8,Y2%I do not want to answer this question7,004/9oFdT/9,?Yk2I cannot answer this question7,007Kt7B7 X,uX*...making you stay in hospital?WDid your heart failure prevent you from living as you wanted during the last month by:Neue Erklaerung Teil 27&7DbdNo0`7&p7Nbd Very little1`7b-d2%7Ybd3lH7b7d470&7dbd Very much57oD7,Y2%I do not want to answer this question7,007oFd7,?Yk2I cannot answer this question7,007K7B`7 X",uX*'...costing you money for medical care?WDid your heart failure prevent you from living as you wanted during the last month by:Neue Erklaerung Teil 2d7&h7DbdNo07&7Nbd Very little1``7b-d2%7Ybd3l7b7d4D 70&P 7dbd Very much5 7o 7,Y2%I do not want to answer this question7,00\ 7oFd| 7,?Yk2I cannot answer this question7,00 7K 7B 7 X#*,uX*,...giving you side effects from medication?WDid your heart failure prevent you from living as you wanted during the last month by:Neue Erklaerung Teil 2\ 7&` 7DbdNo0 7& 7Nbd Very little1` 7b-d2%X 7Ybd3l 7b7d4 70&7dbd Very much5t7o7,Y2%I do not want to answer this question7,00 7oFd,7,?Yk2I cannot answer this question7,00H7K7B7 X+2,uX*?...making you feel you are a burden to your family or friends?WDid your heart failure prevent you from living as you wanted during the last month by:Neue Erklaerung Teil 27& 7DbdNo0x7&7Nbd Very little1`7b-d2%7Ybd3l`7b7d470&7dbd Very much547o\7,Y2%I do not want to answer this question7,007oFd7,?Yk2I cannot answer this question7,007KT7Bt7 X3:,uX*8...making you feel a loss of self-control in your life?WDid your heart failure prevent you from living as you wanted during the last month by:Neue Erklaerung Teil 27&7DbdNo0<7&7Nbd Very little1`7b-d2%7Ybd3l7b7d4p70&|7dbd Very much57o7,Y2%I do not want to answer this question7,007oFd7,?Yk2I cannot answer this question7,0007K7BH7 X;B,uX*...making you worry?WDid your heart failure prevent you from living as you wanted during the last month by:Neue Erklaerung Teil 2p7&t7DbdNo07&7Nbd Very little1`$7b-d2%l7Ybd3l7b7d470&7dbd Very much57o7,Y2%I do not want to answer this question7,00 7oFd@7,?Yk2I cannot answer this question7,00@*K*B* XCJ,uX*B...making it difficult for you to concentrate or remember things?WDid your heart failure prevent you from living as you wanted during the last month by:Neue Erklaerung Teil 2*& *DbdNo0*&(*Nbd Very little1`*b-d2%*Ybd3lX*b7d4*0&l*dbd Very much5|*o*,Y2%I do not want to answer this question7,00X *oFd*,?Yk2I cannot answer this question7,00 *K *B* XKR,uX*...making you feel depressed?WDid your heart failure prevent you from living as you wanted during the last month by:Neue Erklaerung Teil 2*&*DbdNo0 *&*Nbd Very little1`*b-d2%*Ybd3l *b7d4 *0& *dbd Very much5 *o *,Y2%I do not want to answer this question7,00*oFd *,?Yk2I cannot answer this question7,00*------ Total Score Total ScoreTotal@nM~@Rv2 v3 v4 v5 v6 v7 v8 v9 v10 v11 v12 v13 v14 v15 v16 v17 v18 v19 v20 v21 v22 21 sum*------Physical ScorePhysical ScorePhysical@nM~@v3 v4 v5 v6 v7 v8 v13 v14 8 sum*------Emotional ScoreEmotional Score Emotional@nM~@v18 v19 v20 v21 v22 5 sumd*------Total Score (scaled to 0..100)Total Score (scaled to 0..100)Total (scaled)@nM~@Wv2 v3 v4 v5 v6 v7 v8 v9 v10 v11 v12 v13 v14 v15 v16 v17 v18 v19 v20 v21 v22 21 avg 20 **------!Physical Score (scaled to 0..100)!Physical Score (scaled to 0..100)Physical (scaled)@nM~@$v3 v4 v5 v6 v7 v8 v13 v14 8 avg 20 *T*------"Emotional Score (scaled to 0..100)"Emotional Score (scaled to 0..100)Emotional (scaled)@nM~@v18 v19 v20 v21 v22 5 avg 20 *AnyQuest for Windows Questionnaire Definition File 07.09.1999 by Dr. med. Jrg M. Sigle This QDW is based upon the questionnaire Minnesota Living with Heart Failure, by the University of Minnesota, 1986 The wording of the introduction and the layout of the questions have been modified minimally for this electronic version. Original Version Author: Thomas S. Rector, Ph.D. Senior Research Associate Cardiovascular Division University of Minnesota Medical School Twin Cities Campus Box 508 420 Delaware Street S.E. Minneapolis, MN 55455, USA Fax: 612-626-4411 recto001@maroon.tc.umn.edu For information or permission to use it for English contact: Jay N. Cohn, M.D. cohnx001@maroon.tc.umn.edu For information or permission to use for other languages contact: MAPI Research Institute 27 rue de la Villette 69003 Lyon, France Tel. +33-72-13667 Fax +33-72-13667 References: http://www.QLMed.org/mlhfq/index.html http://www.mapi-research-inst.com