AQoL Questionnaire
Time to complete: 3 mins
ID
Your Name
*
First Name
Last Name
Date
*
/
Day
/
Month
Year
My clinician's name is:
Helpful for us, but don't worry if you can't think of their name
Q1
Q2
Q3
Q4
Q5
Q6
1) Because of your health, your relationships (for example: with your friends, partner, or parents) generally:
*
Are very close and warm
Are sometimes close and warm
Are seldom/rarely close and warm
I have no close and warm relationships.
2) Thinking about your relationship with other people:
*
I have plenty of friends, and am never lonely.
Although I have friends, I am occasionally lonely.
Have some friends, but am often lonely for company
I am socially isolated and feel lonely.
3) Thinking about your health and your relationship with your family:
*
My role in the family is unaffected by my health
There are some parts of my family role I cannot carry out.
There are many parts of my family role I cannot carry out.
I cannot carry out any part of my family role.
4) Thinking about how you sleep
*
I can sleep without difficulty most of the time.
My sleep is interrupted some of the time, but I am usually able to go back to sleep without difficulty.
My sleep is interrupted most nights, but I am usually able to go back to sleep without difficulty.
I sleep in short bursts only; I am awake most of the night
5) Thinking about how you generally feel:
*
I do not feel anxious, worried, or depressed.
I am slightly anxious, worried, or depressed.
I feel moderately anxious, worried, or depressed.
I feel extremely anxious, worried, or depressed.
6) How much pain or discomfort do you experience:
*
None at all
I have moderate pain.
I suffer from severe pain.
I suffer unbearable pain.
Any additional comments?
(Not required - leave blank if you like)
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