Adult Quality of Life Surveys

Adult Quality of Life Surveys

QOLS and EQ-5D-5L
This tool has been validated for individuals ages 18 and over.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Last 4 Digit of Social Security Number
How good or bad is your health today?

Click a point on the line to place the orange slider at a spot that best represents your overall health. 0 is the worst health you can imagine, and 100 is the best health you can imagine.
Rate your health from 0 to 100.
QOLS Raw Score
QOLS Adjusted Score
EQ-5D-5L Score

Please select how you feel about each of the following items or situations?*

	Delighted	Pleased	Mostly Satisfied	Mixed	Mostly Dissatisfied	Unhappy	Terrible
Material comforts: home, food, conveniences, financial security
Healh: being physically fit and vigorous
Relationships with parents, siblings, and other relatives
Having (or not having) and rearing children
Relationships with spouse or significant other (or lack of)
Close friends
Helping and encouraging others, volunteering, giving advice
Participating in organizations and public affairs
Learning: attending school, improving knowledge, getting additional knowledge
Understanding yourself: knowing your assets and limitations
Work: job or in home
Expressing yourself creatively
Socializing: meeting other people, doing things, social gatherings
Reading, listening to music, entertainment
Participating in active recreation (sports, etc)
Independence: doing for yourself

MOBILITY*

I have no problems in walking aboutI have slight problems in walking aboutI have moderate problems in walking aboutI have severe problems in walking aboutI am unable to walk about
SELF-CARE*

I have no problems washing or dressing myselfI have slight problems washing or dressing myselfI have moderate problems washing or dressing myselfI have severe problems washing or dressing myselfI am unable to wash or dress myself
USUAL ACTIVITIES (e.g. work‚ study‚ housework‚ family or leisure activities)*

I have no problems doing my usual activitiesI have slight problems doing my usual activitiesI have moderate problems doing my usual activitiesI have severe problems doing my usual activitiesI am unable to do my usual activities
PAIN / DISCOMFORT*

I have no pain or discomfortI have slight pain or discomfortI have moderate pain or discomfortI have severe pain or discomfortI have extreme pain or discomfort
ANXIETY / DEPRESSION*

I am not anxious or depressedI am slightly anxious or depressedI am moderately anxious or depressedI am severely anxious or depressedI am extremely anxious or depressed
Should be Empty:

How good or bad is your health today?