Quality Of Life
This is a survey not a test, there is no wrong answer. Please take your time and answer as honestly as you can. Answers are confidential. Thank you for helping us to help you.
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Peer # *
Your answer
Date
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DD
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YYYY
Year of Birth
Your answer
Race
Your answer
Gender
Your answer
Employed
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How do you feel today *
Your answer
Is this your 1st, 2nd, or 3rd time taking this survey? *
2. How would you rate your quality of life? *
3. How satisfied are you with your health? *
4. To what extent do you feel that physical pain prevents you from doing what you need to do? *
5. How much do you need any medical treatment to function in your daily life? *
6. How much do you enjoy life? *
7. To what extent do you feel your life to be meaningful? *
8. How well are you able to concentrate? *
9. How safe do you feel in your daily life? *
10. How healthy is your physical environment? *
11. Do you have enough energy for everyday life? *
12. Are you able to accept your bodily appearance? *
13. Have you enough money to meet your needs? *
14. How available to you is the information that you need in your day-to-­day life? *
15. To what extent do you have the opportunity for leisure activities? *
16. How well are you able to get around? *
17. How satisfied are you with your sleep? *
18. How satisfied are you with your ability to perform your daily living activities? *
19. How satisfied are you with your capacity for work? *
20. How satisfied are you with your abilities? *
21. How satisfied are you with your personal relationships? *
22. How satisfied are you with your sex life? *
23. How satisfied are you with the support you get from your friends? *
24. How satisfied are you with the conditions of your living place *
25. How satisfied are you with your access to health services? *
26. How satisfied are you with your mode of transportation? *
The following question refers to how often you have felt or experienced certain things in the past 2 weeks.
Your answer
27. How often do you have negative feelings, such as blue mood, despair, anxiety, depression? *
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