Assessment of Quality of Life

Assessment of Quality of Life
Participant Name

First NameLast Name
Date of Birth

MonthDayYear
Date
1. How would you rate your quality of life

Very PoorPoorNeither Poor nor GoodGoodVery Good
2. How satisfied are you with your health?

Very DissatisfiedDissatisfiedNeither Satisfied nor DissatisfiedSatisfiedVery Satisfied
3. To what extent do you feel that physical pain prevents you from doing what you want to do?

Not at allA LittleModeratelyVery MuchAn Extreme Amount
4. How much medical treatment do you need to function in your daily life?

Not at allA LittleModeratelyVery MuchAn Extreme Amount
5. How much do you enjoy life?

Not at AllA LittleModeratelyVery MuchAn Extreme Amount
6. To what extent do you feel your life to be meaningful?

Not at AllA LittleModeratelyVery MuchAn Extreme Amount
7. How well are you able to concentrate?

Not at AllA LittleModeratelyVery MuchExtremely
8. How safe do you feel in your daily life?

Not at AllA LittleModeratelyVery MuchExtremely
9. How healthy is your physical environment?

Not at AllA LittleModeratelyVery MuchExtremely
10. Do you have enough energy for everyday life?

Not at AllA LittleModeratelyMostlyCompletely
11. Are you able to accept your bodily appearance?

Not at AllA LittleModeratelyMostlyCompletely
12. Have you enough money to meet your needs?

Not at AllA LittleModeratelyMostlyCompletely
13. How available is the information that you need in your day-to-day life?

Not at AllA LittleModeratelyMostlyCompletely
14. To what extent do you have the opportunity for leisure activities?

Not at AllA LittleModeratelyMostlyCompletely
15. How well are you able to get around?

Very PoorPoorNeither Poor nor GoodWellVery Well
16. How satisfied are you with your sleep?

Very DissatisfiedDissatisfiedNeither Satisfied nor DissatisfiedSatisfiedVery Satisfied
17. How satisfied are you with your ability to perform your daily living activities?

Very DissatisfiedDissatisfiedNeither Satisfied nor DissatisfiedSatisfiedVery Satisfied
18. How satisfied are you with your capacity for work?

Very DissatisfiedDissatisfiedNeither Satisfied nor DissatisfiedSatisfiedVery Satisfied
19. How satisfied are you with your abilities?

Very DissatisfiedDissatisfiedNeither Satisfied nor DissatisfiedSatisfiedVery Satisfied
20. How satisfied are you with your personal relationships?

Very DissatisfiedDissatisfiedNeither Satisfied nor DissatisfiedSatisfiedVery Satisfied
21. How satisfied are you with your sex life?

Very DissatisfiedDissatisfiedNeither Satisfied nor DissatisfiedSatisfiedVery Satisfied
22. How satisfied are you with the support you get from your friends?

Very DissatisfiedDissatisfiedNeither Satisfied nor DissatisfiedSatisfiedVery Satisfied
23. How satisfied are you with the conditions of your living place?

Very DissatisfiedDissatisfiedNeither Satisfied nor DissatisfiedSatisfiedVery Satisfied
24. How satisfied are you with your access to health services?

Very DissatisfiedDissatisfiedNeither Satisfied nor DissatisfiedSatisfiedVery Satisfied
25. How satisfied are you with your mode of transportation?

Very DissatisfiedDissatisfiedNeither Satisfied nor DissatisfiedSatisfiedVery Satisfied
26. In the past 2 weeks, how often have you had feelings, such as “blue mood,” despair, anxiety and or depression:

NeverSeldomQuite OftenVery OftenAlways
Should be Empty: