171 (171)    MH REPORT (601.93)

Name Value
REPORT NUMBER 171
INSTRUMENT Q-LES-Q-SF
RPT
 |.|.|Quality of Life Enjoyment and Satisfaction Questionnaire - Short
Self-Rating of Overall Satisfaction (Item 16)*: <*Answer_7772*>| |
Critical Items*: <*Answer_7778*>|
<*Answer_7773*>|
       <*Answer_7774*>| |
<*Answer_7775*>|
       <*Answer_7780*>| |
<*Answer_7776*>|
       <*Answer_7781*>| |
<*Answer_7777*>|
       <*Answer_7782*>| |
 Form (Q-LES-Q-SF) |
*Note: All scores reflect respondent satisfaction ratings for "during the 
past week."| |
Questions and Answers | |
Taking everything into consideration, during the past week how satisfied 
have you been with:|
1. Your physical health?|
   <*Answer_8211*>| |
Taking everything into consideration, during the last week how satisfied 
have you been with:|
2. Your mood?|
   |   Date Given: <.Date_Given.>|   Clinician: <.Staff_Ordered_By.>|
   <*Answer_8212*>| |
Taking everything into consideration, during the past week how satisfied 
have you been with:|
3. Your work?|
   <*Answer_8213*>| |
Taking everything into consideration, during the last week how satisfied 
have you been with:|
4. Your household activities?|
   <*Answer_8214*>| |
Taking everything into consideration, during the past week how satisfied 
   Location:  <.Location.>|   |   Veteran: <.Patient_Name_Last_First.>|
have you been with:|
5. Your social relationships?|
   <*Answer_8215*>| |
Taking everything into consideration, during the last week how satisfied 
have you been with:|
6. Your family relationships?|
   <*Answer_8216*>| |
Taking everything into consideration, during the past week how satisfied 
have you been with:|
7. Your leisure time activities?|
   SSN: <.Patient_SSN.>|
   <*Answer_8217*>| |
Taking everything into consideration, during the last week how satisfied 
have you been with:|
8. Your ability to function in daily life?|
   <*Answer_8218*>| |
Taking everything into consideration, during the past week how satisfied 
have you been with:|
9. Your sexual drive, interest and/or performance?|
   <*Answer_8219*>| |
Taking everything into consideration, during the last week how satisfied
   DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)|
have you been with:|
10. Your economic status?|
    <*Answer_8220*>| |
Taking everything into consideration, during the past week how satisfied 
have you been with:|
11. Your living/housing situation?|
    <*Answer_8221*>| |
Taking everything into consideration, during the last week how satisfied 
have you been with:|
12. Your ability to get around physically without feeling dizzy or|
   Gender: <.Patient_Gender.>| |
    unsteady or falling?|
    <*Answer_8222*>| |
Taking everything into consideration, during the past week how satisfied 
have you been with:|
13. Your vision in terms of ability to do work or hobbies?|
    <*Answer_8223*>| |
Taking everything into consideration, during the last week how satisfied 
have you been with:|
14. Your overall sense of well-being?|
    <*Answer_8224*>| |
Quality of Life/Life Enjoyment Percent of Max Score*: <*Answer_7779*>%|
Taking everything into consideration, during the past week how satisfied 
have you been with:|
15. Your medication?|
    <*Answer_8225*>| |
Taking everything into consideration, during the last week how satisfied 
have you been with:|
16. How would you rate your overall life satisfaction and contentment
during the past week?|
    <*Answer_8226*>| |
 Information contained in this note is based on a self-report assessment|
Satisfaction with Medications (Item 15)*: <*Answer_7771*> |
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.| |
 The Q-LES-Q-SF is copyrighted by Jean Endicott, Ph.D. Permission granted|
to electronically reproduce for clinicians use and research in|
non-industry studies. For other uses, contact copyright holder.| |
 
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