| RPT |
.| .| QOLIE-10| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.>
Services and the QOLIE| Development Group.| | 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_Age.>)| Gender: <.Patient_Gender.>| | | QOLIE - 10: <-QOLIE - 10->| | Questions and Answers| | 1. Did you have a lot of energy?| <*Answer_6687*>| 2. Have you felt downhearted and
low?| <*Answer_6688*>| 3. Driving (or other transport)?| <*Answer_6689*>| 4. How much do your work limitations bother you?| <*Answer_6690*>| 5. How much do your social limitations bother
you?| <*Answer_6691*>| 6. How much do your memory difficulties bother you?| <*Answer_6692*>| 7. How much do physical effects of antiepileptic drugs bother you?| <*Answer_6693*>| 8. How
much do psychological effects of antiepileptic drugs bother you?| <*Answer_6694*>| 9. How afraid are you of having a seizure during the next 4 weeks?| <*Answer_6695*>| 10. How has your
QUALITY OF LIFE been during the past 4 weeks (that is, how have things been going for you)?| <*Answer_6696*>| 11. How much does the state of your epilepsy-related quality of life distress you
overall?| <*Answer_7176*>| 12a. Energy (tiredness)| <*Answer_7177*>| 12b. Emotions (mood)| <*Answer_7178*>| 12c. Daily activities (work, driving, social)| <*Answer_7179*>| 12d. Mental
activity (thinking, concentrating, memory)| <*Answer_7180*>| 12e. Medication effects (physical, mental)| <*Answer_7181*>| 12f. Worry about fits (impact of fits)| <*Answer_7182*>| 12g.
Overall quality of life| <*Answer_7183*>| | copyright (c) 1996, Epilepsy Therapy Project, QOLIE Development Group; Adapted from | the QOLIE-10,copyright (c) 1993, Professional Postgraduate
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