N˚ of the item order with a summary of the item

“Worst” score (the highest )

“Best” score (the lowest)

Physical dimension (8 items)

2- Need some rest throughout the day

3- Difficult stairs climbing and descending

4- Limited usual household chores

5- Limited external movements

6- Sleep disruption 7- Relations and activities with the others 12- Shortness of breath 13- Tiredness, lassitude, lack of energy

40: Very limited when achieving any physical activity.

0: Conducts any physical activity, including the most intense ones, without any restrictions due to medical condition.

Emotional dimension (5 items)

17- Charge, burden for the others 18- Loss of control and self-control 19- Concerned, anxious 20- Concentration, memory disorders 21- Sensation of depression

25: anxiety, depression and impression of being a burden to the family.

0: feels quiet and calm at any time.

Other items (non gathered)

1- Swelling of ankles and legs

8- Difficult remunerative work

9- Difficult leisure and hobbies activities 10- Difficult sexual activities

11- Limitation of the favorite meals 14- Frequent hospital admissions

15- Additional health expenditures

16- Side effects of treatments

5 For each item: extreme discomfort related to the question.

0 For each item: no discomfort related to the question.

Global dimension (all the 21 items)

105: very limited to do all the physical activities. Very depressed, tired, with a strong impression of being a burden for the others.

0: conducts all the physical activities, enjoys life events.