for the Study of
Healthcare Organizations & Transactions
Problems and Complaints Questionnaire
- Vomiting (WOMEN: when you weren't
- Abdominal or belly pain (WOMEN:
when you weren't menstruating).
- Nausea (feeling sick to your
stomach, but not actually vomiting).
- Excessive gas or bloating of your
stomach or abdomen.
- Loose bowels or diarrhea.
- Foods you cannot eat because they
make you sick.
- Pain in your arms or legs (other
than the joints).
- Back pain.
- Pain in your joints.
- Pain when you urinate.
- Other pains (do not count
- Shortness of breath (when not
really exerting yourself).
- Heart racing, pounding, or
- Chest pain.
- Amnesia, a period of several hours
or days after which you could not remember what happened.
- Trouble swallowing or lump in your
- Losing your voice (for more than a
- Complete deafness for a period of
- Double vision for a period of time.
- Blurred vision (when you did not
- Complete blindness for more than a
- Fainting spells or loss of
consciousness (except due to diagnosed epilepsy).
- Seizures or convulsions (except due
to diagnosed epilepsy).
- Trouble walking (or other
impairment of coordination or balance).
- Paralysis, or periods of weakness
when you could not lift or move things normally.
- Complete inability to urinate for a
whole day (other than after childbirth or surgery).
- Burning sensations in your sexual
organs or rectum (other than during sexual intercourse).
- Your sex life is unimportant to
you, and you feel you could get along all right without it.
- Sex is often physically painful.
- Other sexual problems (MEN: such as
not being able to obtain an erection or to ejaculate).
- WOMEN: Very painful menstrual
periods (other than during your first year of menstruation).
- WOMEN: Irregular menstrual periods
(other than during your first year of menstruation, or during menopause).
- WOMEN: Excessive bleeding during
- WOMEN: Vomiting throughout one or