| RPT |
|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.>)
|
