I feel close to my partner (or the person who is my main
support)
..........................................................................................
0
1
2
3
4
Q1
Regardless of your current level of sexual activity, please
answer the following question. If you prefer not to answer it,
please mark this box
and go to the next section.
GS7
I am satisfied with my sex life
.......................................................
0
1
2
3
4

FACT-Ga (Version 4)
Please circle or mark one number per line to indicate your response as it applies to the past 7
days
.
EMOTIONAL WELL-BEING
Not
at all
A little
bit
Some-
what
Quite
a bit
Very
much
GE1
I feel sad
.........................................................................................
0
1
2
3
4
GE2
I am satisfied with how I am coping with my illness
.....................
0
1
2
3
4
GE3
I am losing hope in the fight against my illness
.............................
0
1
2
3
4
GE4
I feel nervous
..................................................................................
0
1
2
3
4
GE5
I worry about dying
........................................................................
0
1
2
3
4
GE6
I worry that my condition will get worse
.......................................
0
1
2
3
4
FUNCTIONAL WELL-BEING
Not
at all
A little
bit
Some-
what
Quite
a bit
Very
much
GF1
I am able to work (include work at home)
.....................................
0
1
2
3
4
GF2
My work (include work at home) is fulfilling
................................
0
1
2
3
4
GF3
I am able to enjoy life
....................................................................
0
1
2
3
4
GF4
I have accepted my illness
.............................................................
0
1
2
3
4
GF5
I am sleeping well
..........................................................................
0
1
2
3
4


You've reached the end of your free preview.
Want to read all 4 pages?
- Fall '16
- Jeff Miller