347 (347)    MH REPORT (601.93)

|ALS-Specific Quality of Life - Short Form (ALSSQOL-SF)
|   Gender: <.Patient_Gender.>
|  
|<*Answer_7771*>
|  
|  
|Questions and Answers:
|  
|   Please assess your overall quality of life over the past week
|   (7 days). Considering all parts of my life - physical, emotional,
|   social, spiritual, and financial - over the past week, the quality
|  
|   of my life has been:
|   <*Answer_9556*>
|
|   1.  I have experienced pain.
|       <*Answer_9529*>
|   2.  I have experienced fatigue.
|       <*Answer_9530*>
|   3.  I have experienced excessive saliva.
|       <*Answer_9531*>
|   4.  I have experienced problems with speaking.
|   Date Given: <.Date_Given.>
|       <*Answer_9532*>
|   5.  I have experienced problems with my strength and ability to move.
|       <*Answer_9533*>
|   6.  I have experienced problems with sleep.
|       <*Answer_9534*>
|   7.  I have felt physically terrible.
|       <*Answer_9535*>
|   8.  The world has been caring and responsive to my needs.
|       <*Answer_9536*>
|   9.  I have felt supported.
|   Clinician: <.Staff_Ordered_By.>
|       <*Answer_9537*>
|  10.  I have been depressed.
|       <*Answer_9538*>
|  11.  Relationships with those closest to me have been satisfying.
|       <*Answer_9539*>
|  12.  My religion has been a source of strength or comfort to me.
|       <*Answer_9540*>
|  13.  I consider myself to have been religious or spiritual.
|       <*Answer_9541*>
|  14.  I have felt hopeless.
|   Location:  <.Location.>
|       <*Answer_9542*>
|  15.  I have felt sad.
|       <*Answer_9543*>
|  16.  I have enjoyed the beauty of my surroundings.
|       <*Answer_9544*>
|  17.  My desire for emotional intimacy has been strong.
|       <*Answer_9545*>
|  18.  I have shared emotional intimacy with others.
|       <*Answer_9546*>
|  19.  My desire for physical intimacy has been strong.
|  
|       <*Answer_9547*>
|  20.  I have shared physical intimacy with others.
|       <*Answer_9548*>
|  
|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.

|   Veteran:  <.Patient_Name_Last_First.>
|   SSN: <.Patient_SSN.>
|   DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)