| RPT |
.| .| World Health Organization: Quality of Life - BREF| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN:
<*Answer_6623*>| 20. How satisfied are you with your personal relationships?| <*Answer_6624*>| 21. How satisfied are you with your sex life?| <*Answer_6625*>| 22. How satisfied are you
with the support you get from your friends?| <*Answer_6626*>| 23. How satisfied are you with the conditions of your living place?| <*Answer_6627*>| 24. How satisfied are you with your access
to health services?| <*Answer_6628*>| 25. How satisfied are you with your transport?| <*Answer_6629*>| 26. How often do you have negative feelings such as blue mood, despair, anxiety,
depression?| <*Answer_6630*>| 27. Do you have any comments about the assessment? Type "none" or "NA" for no comment.| <*Answer_6631*>| | | Information contained in this note is based on a
self-report assessment and is not sufficient to use alone for diagnostic purposes. Assessment results should be verified for accuracy and used in conjunction with other diagnostic activities and
procedures.| $~
<.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | <.DLL_String.>| | | Questions and Answers| | 1. How would you rate your quality of life?|
<*Answer_6605*>| 2. How satisfied are you with your health?| <*Answer_6606*>| 3. To what extent do you feel that physical pain prevents you from doing what you need to do?| <*Answer_6607*>|
4. How much do you need any medical treatment to function in your daily life?| <*Answer_6608*>| 5. How much do you enjoy life?| <*Answer_6609*>| 6. To what extent do you feel your life to be
meaningful?| <*Answer_6610*>| 7. How well are you able to concentrate?| <*Answer_6611*>| 8. How safe do you feel in your daily life?| <*Answer_6612*>| 9. How healthy is your physical
environment?| <*Answer_6613*>| 10. Do you have enough energy for everyday life?| <*Answer_6614*>| 11. Are you able to accept your bodily appearance?| <*Answer_6615*>| 12. Have you enough
money to meet your needs?| <*Answer_6616*>| 13. How available to you is the information that you need in your day-to-day life?| <*Answer_6617*>| 14. To what extent do you have the opportunity
for leisure activities?| <*Answer_6618*>| 15. How well are you able to get around?| <*Answer_6619*>| 16. How satisfied are you with your sleep?| <*Answer_6620*>| 17. How satisfied are you
with your ability to perform your daily living activities?| <*Answer_6621*>| 18. How satisfied are you with your capacity for work?| <*Answer_6622*>| 19. How satisfied are you with yourself?|
|
