Adult Quality of Life Surveys
QOLS and EQ-5D-5L
This tool has been validated for individuals ages 18 and over.
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
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 about
I have slight problems in walking about
I have moderate problems in walking about
I have severe problems in walking about
I am unable to walk about
SELF-CARE
*
I have no problems washing or dressing myself
I have slight problems washing or dressing myself
I have moderate problems washing or dressing myself
I have severe problems washing or dressing myself
I 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 activities
I have slight problems doing my usual activities
I have moderate problems doing my usual activities
I have severe problems doing my usual activities
I am unable to do my usual activities
PAIN / DISCOMFORT
*
I have no pain or discomfort
I have slight pain or discomfort
I have moderate pain or discomfort
I have severe pain or discomfort
I have extreme pain or discomfort
ANXIETY / DEPRESSION
*
I am not anxious or depressed
I am slightly anxious or depressed
I am moderately anxious or depressed
I am severely anxious or depressed
I am extremely anxious or depressed
Submit
Should be Empty: