Table 1

The Symptom Impact Questionnaire (SIQR)

Domain 1: For each question, place an "X" in the box that best indicates how much difficulty you have experienced in doing the following activities during the past 7 days. If you did not perform a particular activity in the last 7 days, rate the difficulty for the last time you performed the activity. If you can't perform an activity, check the last box.

Brush or comb your hair

No difficulty

□ □ □ □ □ □ □ □ □ □ □

Very difficult

Walk continuously for 20 minutes

No difficulty

□ □ □ □ □ □ □ □ □ □ □

Very difficult

Prepare a homemade meal

No difficulty

□ □ □ □ □ □ □ □ □ □ □

Very difficult

Vacuum, scrub or sweep floors

No difficulty

□ □ □ □ □ □ □ □ □ □ □

Very difficult

Lift and carry a bag full of groceries

No difficulty

□ □ □ □ □ □ □ □ □ □ □

Very difficult

Climb one flight of stairs

No difficulty

□ □ □ □ □ □ □ □ □ □ □

Very difficult

Change bed sheets

No difficulty

□ □ □ □ □ □ □ □ □ □ □

Very difficult

Sit in a chair for 45 minutes

No difficulty

□ □ □ □ □ □ □ □ □ □ □

Very difficult

Go shopping for groceries

No difficulty

□ □ □ □ □ □ □ □ □ □ □

Very difficult

Domain 2: For each of the following 2 questions, check the one box that best describes the overall impact of any medical problems over the last 7 days.

My medical problems prevented me from accomplishing goals.

Never

□ □ □ □ □ □ □ □ □ □ □

Always

I was completely overwhelmed by my medical problems

Never

□ □ □ □ □ □ □ □ □ □ □

Always

Domain 3: For each of the following 10 questions, check the one box that best indicates the intensity of the following common symptoms over the last 7 days.

Please rate your level of pain

No pain

□ □ □ □ □ □ □ □ □ □ □

Unbearable pain

Please rate your level of energy

Lots of energy

□ □ □ □ □ □ □ □ □ □ □

No energy

Please rate your level of stiffness

No stiffness

□ □ □ □ □ □ □ □ □ □ □

Severe stiffness

Please rate the quality of your sleep

Awoke rested

□ □ □ □ □ □ □ □ □ □ □

Awoke very tired

Please rate your level of depression

No depression

□ □ □ □ □ □ □ □ □ □ □

Very depressed

Please rate your level of memory problems

Good memory

□ □ □ □ □ □ □ □ □ □ □

Very poor memory

Please rate your level of anxiety

Not anxious

□ □ □ □ □ □ □ □ □ □ □

Very anxious

Please rate your level of tenderness to touch

No tenderness

□ □ □ □ □ □ □ □ □ □ □

Very tender

Please rate your level of balance problems

No imbalance

□ □ □ □ □ □ □ □ □ □ □

Severe imbalance

Please rate your level of sensitivity to loud noises, bright lights, odors and cold

No sensitivity

□ □ □ □ □ □ □ □ □ □ □

Extreme sensitivity

Scoring: (1) Sum the scores for each of the three domains (Function, Overall and Symptoms). (2) Divide domain 1 score by 3, divide domain 2 score by 1 (that is, unchanged) and divide domain score 3 by 2. (3) Add the three resulting domain scores to obtain the total SIQR score (range, 0 to 100).

Friend and Bennett Arthritis Research & Therapy 2011 13:R58   doi:10.1186/ar3311