109 (109)    MH REPORT (601.93)

.| .| 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