| RPT |
.| .| Quality of Life in Epilespy - QOLIE-31| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB:
Driving?| <*Answer_7203*>| 21. How fearful are you of having a seizure during the next month?| <*Answer_7204*>| 22. Do you worry about hurting yourself during a seizure?| <*Answer_7205*>|
23. How worried are you about embarrassment or other social problems resulting from having a seizure during the next month?| <*Answer_7206*>| 24. How worried are you that medications you are
taking will be bad for you if taken for a long time?| <*Answer_7207*>| 25. Seizures| <*Answer_7208*>| 26. Memory difficulties| <*Answer_7209*>| 27. Work limitations| <*Answer_7210*>|
28. Social limitations| <*Answer_7211*>| 29. Physical effects of antiepileptic medication| <*Answer_7212*>| 30. Mental effects of antiepileptic medication| <*Answer_7213*>| 31. How good
or bad do you think your health is?| <*Answer_7214*>| 32. Comments (if any)| <*Answer_7215*>| | Copyright 1993, RAND. All Rights reserved. The QOLIE-31 was developed in cooperation with
Professional Postgraduate Services, a division of Phys World Comm Group, 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_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | <.DLL_String.>| | Questions and Answers| | 1. Overall, how would you rate your quality of life?| <*Answer_7184*>| 2.
Did you feel full of pep?| <*Answer_7185*>| 3. Have you been a very nervous person?| <*Answer_7186*>| 4. Have you felt so down in the dumps that nothing could cheer you up?|
<*Answer_7187*>| 5. Have you felt calm and peaceful?| <*Answer_7188*>| 6. Did you have a lot of energy?| <*Answer_7189*>| 7. Have you felt downhearted and blue?| <*Answer_7190*>| 8. Did
you feel worn out?| <*Answer_7191*>| 9. Have you been a happy person?| <*Answer_7192*>| 10. Did you feel tired?| <*Answer_7193*>| 11. Have you worried about having another seizure?|
<*Answer_7194*>| 12. Did you have difficulty reasoning and solving problems (such as making plans, making decisions, learning new things)?| <*Answer_7195*>| 13. Has your health limited your
social activities (such as visiting with friends or close relatives)?| <*Answer_7196*>| 14. How has the QUALITY OF YOUR LIFE been during the past 4 weeks (that is, how have things been going for
you)?| <*Answer_7197*>| 15. In the past 4 weeks, have you had any trouble with your memory?| <*Answer_7198*>| 16. Trouble remembering things people tell you?| <*Answer_7199*>| 17. Trouble
concentrating or reading?| <*Answer_7200*>| 18. Trouble concentrating or doing one thing at a time?| <*Answer_7201*>| 19. Leisure time (such as hobbies, going out)?| <*Answer_7202*>| 20.
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