QOL-10

1

Patient Name* This field is required.

First Name

Last Name

2

UniqueID* This field is required.

3

What is the patient's email?

4

This is a 10 question assessment of quality of life. Answers to the questions are: "very poor", "poor", "neither poor nor good", "good", and "very good". To assess progress with treatment "quality of life" will be assessed every 6 months.

5

How do you consider your physical health at the moment?* This field is required.

very poor

poor

neither poor nor good

good

very good

6

How do you consider your mental health at the moment?* This field is required.

very poor

poor

neither poor nor good

good

very good

8

How are your relationships with your friends at the moment?* This field is required.

very poor

poor

neither poor nor good

good

very good

9

How is your relationship with your partner at the moment?* This field is required.

very poor

poor

neither poor nor good

good

very good

10

How do you consider your ability to love at the moment?* This field is required.

very poor

poor

neither poor nor good

good

very good

11

How do you consider your sexual functioning at the moment?* This field is required.

very poor

poor

neither poor nor good

good

very good

12

How do you consider your social functioning at the moment?* This field is required.

very poor

poor

neither poor nor good

good

very good

15

Today's Provider* This field is required.

16

Screening Test

17

Date

18

Score