Your Wellness Journey Begins Here
Personal Information
Uncover your goals and personalize your path
Name
*
First Name
Last Name
Age
*
Under 18
18-24
25-34
35-44
45-54
55-64
Above 64
Gender
*
Male
Female
Phone Number
Please enter a valid phone number.
Email
*
example@example.com
Quality of Life Assessment for Older Adults Questionnaire
Instructions for the Patient: Please select the option that best describes your current experience with each statement. Your honest and thoughtful responses will aid in understanding your current state and determining if further evaluation is warranted.
1. Cognitive Function: I feel mentally sharp and clear.
Never (1)
Rarely (2)
Sometimes (3)
Often (4)
Always (5)
Score 1
2. Physical Mobility: I can move around easily and comfortably.
Never (1)
Rarely (2)
Sometimes (3)
Often (4)
Always (5)
Score 2
3. Energy Levels: I have enough energy for my daily activities.
Never (1)
Rarely (2)
Sometimes (3)
Often (4)
Always (5)
Score 3
4. Sleep Quality: I am satisfied with my sleep quality.
Never (1)
Rarely (2)
Sometimes (3)
Often (4)
Always (5)
Score 4
5. Emotional Well-being: I feel content and positive about life.
Never (1)
Rarely (2)
Sometimes (3)
Often (4)
Always (5)
Score 5
6. Social Participation: I engage in social activities that I enjoy.
Never (1)
Rarely (2)
Sometimes (3)
Often (4)
Always (5)
Score 6
7. Nutritional Status: I maintain a well-balanced and nutritious diet.
Never (1)
Rarely (2)
Sometimes (3)
Often (4)
Always (5)
Score 7
8. Pain and Discomfort: I am free from pain and discomfort.
Never (1)
Rarely (2)
Sometimes (3)
Often (4)
Always (5)
Score 8
9. Medication Adherence: I take my medications as prescribed.
Never (1)
Rarely (2)
Sometimes (3)
Often (4)
Always (5)
Score 9
10. Mental Health: I feel mentally healthy and stable.
Never (1)
Rarely (2)
Sometimes (3)
Often (4)
Always (5)
Score 10
11. Daily Living Skills: I can manage my daily activities without assistance.
Never (1)
Rarely (2)
Sometimes (3)
Often (4)
Always (5)
Score 11
12. Health Self-Perception: I feel my health is excellent compared to others my age.
Never (1)
Rarely (2)
Sometimes (3)
Often (4)
Always (5)
Score 12
13. Physical Activity: I am physically active and engage in regular exercise.
Never (1)
Rarely (2)
Sometimes (3)
Often (4)
Always (5)
Score 13
14. Management of Chronic Conditions: My health conditions are well-managed.
Never (1)
Rarely (2)
Sometimes (3)
Often (4)
Always (5)
Score 14
15. Sensory Abilities: My vision and hearing are adequate for daily life.
Never (1)
Rarely (2)
Sometimes (3)
Often (4)
Always (5)
Score 15
16. Mobility Aids Use: If I use mobility aids, they meet my needs effectively.
Never (1)
Rarely (2)
Sometimes (3)
Often (4)
Always (5)
Score 16
17. Coping Skills: I manage stress and adapt to changes well.
Never (1)
Rarely (2)
Sometimes (3)
Often (4)
Always (5)
Score 17
18. Functional Abilities: I maintain independence in daily functions like bathing and dressing.
Never (1)
Rarely (2)
Sometimes (3)
Often (4)
Always (5)
Score 18
19. Life Satisfaction: I am satisfied with my current stage of life.
Never (1)
Rarely (2)
Sometimes (3)
Often (4)
Always (5)
Score 19
Final Score
Scoring:
Score 20-40: May indicate significant health concerns or impairments in quality of life; a comprehensive clinical assessment is recommended.Score 41-60: Suggests possible issues that may need medical attention or lifestyle modifications; professional consultation is advised.Score 61-80: Reflects a moderate level of wellbeing; routine health check-ups and continued monitoring are suggested.Score 81-100: Indicates a high level of wellbeing; maintain current health practices and lifestyle.
Based on your responses, we may recommend Hyperbaric Oxygen Therapy (HBOT) as a potential treatment option. For a deeper understanding of HBOT, a brief video is available below. If you'd like to discuss your specific needs with a consultant, simply click the "Make Appointment" button and we will be in touch shortly.
Disclaimer of Liability
This questionnaire is intended for initial assessment purposes only and is not to be used as a diagnostic tool. It does not replace professional medical evaluation, diagnosis, or treatment. Always seek the advice of your physician or other qualified healthcare provider regarding any medical condition or before starting any new treatment. If in doubt about your health, seek medical assistance immediately. Usage of this questionnaire does not create a doctor-patient relationship with Boost Asia Ltd. or its affiliates.
Make Appointment
Should be Empty: