Assessment of Quality of Life
Participant Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
1. How would you rate your quality of life
Very Poor
Poor
Neither Poor nor Good
Good
Very Good
2. How satisfied are you with your health?
Very Dissatisfied
Dissatisfied
Neither Satisfied nor Dissatisfied
Satisfied
Very Satisfied
3. To what extent do you feel that physical pain prevents you from doing what you want to do?
Not at all
A Little
Moderately
Very Much
An Extreme Amount
4. How much medical treatment do you need to function in your daily life?
Not at all
A Little
Moderately
Very Much
An Extreme Amount
5. How much do you enjoy life?
Not at All
A Little
Moderately
Very Much
An Extreme Amount
6. To what extent do you feel your life to be meaningful?
Not at All
A Little
Moderately
Very Much
An Extreme Amount
7. How well are you able to concentrate?
Not at All
A Little
Moderately
Very Much
Extremely
8. How safe do you feel in your daily life?
Not at All
A Little
Moderately
Very Much
Extremely
9. How healthy is your physical environment?
Not at All
A Little
Moderately
Very Much
Extremely
10. Do you have enough energy for everyday life?
Not at All
A Little
Moderately
Mostly
Completely
11. Are you able to accept your bodily appearance?
Not at All
A Little
Moderately
Mostly
Completely
12. Have you enough money to meet your needs?
Not at All
A Little
Moderately
Mostly
Completely
13. How available is the information that you need in your day-to-day life?
Not at All
A Little
Moderately
Mostly
Completely
14. To what extent do you have the opportunity for leisure activities?
Not at All
A Little
Moderately
Mostly
Completely
15. How well are you able to get around?
Very Poor
Poor
Neither Poor nor Good
Well
Very Well
16. How satisfied are you with your sleep?
Very Dissatisfied
Dissatisfied
Neither Satisfied nor Dissatisfied
Satisfied
Very Satisfied
17. How satisfied are you with your ability to perform your daily living activities?
Very Dissatisfied
Dissatisfied
Neither Satisfied nor Dissatisfied
Satisfied
Very Satisfied
18. How satisfied are you with your capacity for work?
Very Dissatisfied
Dissatisfied
Neither Satisfied nor Dissatisfied
Satisfied
Very Satisfied
19. How satisfied are you with your abilities?
Very Dissatisfied
Dissatisfied
Neither Satisfied nor Dissatisfied
Satisfied
Very Satisfied
20. How satisfied are you with your personal relationships?
Very Dissatisfied
Dissatisfied
Neither Satisfied nor Dissatisfied
Satisfied
Very Satisfied
21. How satisfied are you with your sex life?
Very Dissatisfied
Dissatisfied
Neither Satisfied nor Dissatisfied
Satisfied
Very Satisfied
22. How satisfied are you with the support you get from your friends?
Very Dissatisfied
Dissatisfied
Neither Satisfied nor Dissatisfied
Satisfied
Very Satisfied
23. How satisfied are you with the conditions of your living place?
Very Dissatisfied
Dissatisfied
Neither Satisfied nor Dissatisfied
Satisfied
Very Satisfied
24. How satisfied are you with your access to health services?
Very Dissatisfied
Dissatisfied
Neither Satisfied nor Dissatisfied
Satisfied
Very Satisfied
25. How satisfied are you with your mode of transportation?
Very Dissatisfied
Dissatisfied
Neither Satisfied nor Dissatisfied
Satisfied
Very Satisfied
26. In the past 2 weeks, how often have you had feelings, such as “blue mood,” despair, anxiety and or depression:
Never
Seldom
Quite Often
Very Often
Always
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