AQoL-4D

AQoL Questionnaire

Time to complete: 3 mins
ID
Your Name*

First NameLast Name
Date*

DayMonthYear
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 warmAre sometimes close and warmAre seldom/rarely close and warmI 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 companyI 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 healthThere 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 allI have moderate pain.I suffer from severe pain.I suffer unbearable pain.
Any additional comments?
(Not required - leave blank if you like)
Done! Please click submit below. Thanks!
Should be Empty:

AQoL Questionnaire