Check the boxes below according to the severity of the symptoms you experience and their impact on daily-living function. Add up your total score using the values of the boxes you selected and show the completed form to your doctor so you can both use the results to track your progress.
I am frustrated by my MG
0
I have trouble with my eyes because of my MG (e.g., double vision)
I have trouble eating because of my MG
I have limited my social activity because of my MG
My MG limits my ability to enjoy hobbies and fun activities
I have trouble meeting the needs of my family because of my MG
I have to make plans around my MG
I am bothered by limitations in performing my work (including work at home) because of my MG
I have difficulty speaking due to my MG
I have lost some personal independence because of my MG (e.g., driving, shopping, running errands)
I am depressed about my MG
I have trouble walking due to my MG
I have trouble getting around public places because of my MG
I feel overwhelmed by my MG
I have trouble performing my personal grooming needs due to my MG
Not at all=0
Somewhat=1
Very much=2
Patient name:
Date:
Total score
(sum of values)
(out of 30)
Patient name: xxxxx
Date: xxxxx
Total Score 0
MG-QoL15r assessment adapted from Burns TM, et al. 2016.1 The information on this page is intended as educational information for healthcare providers. It does not replace a healthcare provider’s judgment or clinical diagnosis.
references:
Burns TM, et al. Muscle Nerve. 2016;54(6):1015-1022.
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