FACT-BMT
| Not at all | A little bit | Some-what | Quite a bit | Very much | ||
|---|---|---|---|---|---|---|
| Physical well-being | ||||||
| GP1 | I have a lack of energy. | 0 | 1 | 2 | 3 | 4 |
| GP2 | I have nausea. | 0 | 1 | 2 | 3 | 4 |
| GP3 | Because of my physical condition, I have trouble meeting the needs of my family. | 0 | 1 | 2 | 3 | 4 |
| GP4 | I have pain. | 0 | 1 | 2 | 3 | 4 |
| GP5 | I am bothered by side effects of treatment. | 0 | 1 | 2 | 3 | 4 |
| GP6 | I feel ill. | 0 | 1 | 2 | 3 | 4 |
| GP7 | I am forced to spend time in bed. | 0 | 1 | 2 | 3 | 4 |
| Social/family well-being | ||||||
| GS1 | I feel close to my friends. | 0 | 1 | 2 | 3 | 4 |
| GS2 | I get emotional support from my family. | 0 | 1 | 2 | 3 | 4 |
| GS3 | I get support from my friends. | 0 | 1 | 2 | 3 | 4 |
| GS4 | My family has accepted my illness. | 0 | 1 | 2 | 3 | 4 |
| GS5 | I am satisfied with family communication about my illness. | 0 | 1 | 2 | 3 | 4 |
| GS6 | 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 |
| Emotional well-being | ||||||
| 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 | ||||||
| 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 |
| GF6 | I am enjoying the things I usually do for fun. | 0 | 1 | 2 | 3 | 4 |
| GF7 | I am content with the quality of my life right now. | 0 | 1 | 2 | 3 | 4 |
| Additional concerns | ||||||
| BMT1 | I am concerned about keeping my job (include work at home). | 0 | 1 | 2 | 3 | 4 |
| BMT2 | I feel distant from other people. | 0 | 1 | 2 | 3 | 4 |
| BMT3 | I worry that the transplant will not work. | 0 | 1 | 2 | 3 | 4 |
| BMT4 | The side effects of treatment are worse than I had imagined. | 0 | 1 | 2 | 3 | 4 |
| C6 | I have a good appetite. | 0 | 1 | 2 | 3 | 4 |
| C7 | I like the appearance of my body. | 0 | 1 | 2 | 3 | 4 |
| BMT5 | I am able to get around by myself. | 0 | 1 | 2 | 3 | 4 |
| BMT6 | I get tired easily. | 0 | 1 | 2 | 3 | 4 |
| BL4 | I am interested in sex. | 0 | 1 | 2 | 3 | 4 |
| BMT7 | I have concerns about my ability to have children. | 0 | 1 | 2 | 3 | 4 |
| BMT8 | I have confidence in my nurse(s). | 0 | 1 | 2 | 3 | 4 |
| BMT9 | I regret having the bone marrow transplant | 0 | 1 | 2 | 3 | 4 |
| BMT10 | I can remember things. | 0 | 1 | 2 | 3 | 4 |
| Br1 | I am able to concentrate. | 0 | 1 | 2 | 3 | 4 |
| BMT11 | I have frequent colds/infections. | 0 | 1 | 2 | 3 | 4 |
| BMT12 | My eyesight is blurry. | 0 | 1 | 2 | 3 | 4 |
| BMT13 | I am bothered by a change in the way food tastes | 0 | 1 | 2 | 3 | 4 |
| BMT14 | I have tremors. | 0 | 1 | 2 | 3 | 4 |
| B1 | I have been short of breath. | 0 | 1 | 2 | 3 | 4 |
| BMT15 | I am bothered by skin problems (eg, rash, itching) | 0 | 1 | 2 | 3 | 4 |
| BMT16 | I have trouble with my bowels. | 0 | 1 | 2 | 3 | 4 |
| BMT17 | My illness is a personal hardship for my close family members. | 0 | 1 | 2 | 3 | 4 |
| BMT18 | The cost of my treatment is a burden on me or my family. | 0 | 1 | 2 | 3 | 4 |
Above is a list of statements that other people with your illness have said are important. Please circle or mark one number per line to indicate your response as it applies to the past 7 days.