| RPT |
|.|.|Quality of Life Enjoyment and Satisfaction Questionnaire - Short
Self-Rating of Overall Satisfaction (Item 16)*: <*Answer_7772*>| |
*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
Form (Q-LES-Q-SF) |
have you been with:|
2. Your mood?|
<*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?|
| Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>|
<*Answer_8214*>| |
Taking everything into consideration, during the past week how satisfied
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
Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>|
have you been with:|
7. Your leisure time activities?|
<*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?|
SSN: <.Patient_SSN.>|
<*Answer_8219*>| |
Taking everything into consideration, during the last week how satisfied
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
DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)|
have you been with:|
12. Your ability to get around physically without feeling dizzy or|
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:|
Gender: <.Patient_Gender.>| |
14. Your overall sense of well-being?|
<*Answer_8224*>| |
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?|
Quality of Life/Life Enjoyment Percent of Max Score*: <*Answer_7779*>%|
<*Answer_8226*>| |
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.| |
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.| |
$~
Satisfaction with Medications (Item 15)*: <*Answer_7771*> |
|
