Wisconsin Quality of Life Index for Adults – A-QLI

In general, would you say your physical health is poor, fair, good, very good, or excellent?

Compared to one year ago, how would you rate your health in general now?

Compared to others my age, my health is as good as can be expected.

I expect my health to get worse.

During the past four weeks, did your physical health limit the kind of activities you could do?

During the past four weeks, did your physical health limit the amount of activities you would like to do?

During the past four weeks, did your physical health limit you in performing self-care?

In the past four weeks, has your health limited you in moderate activities, such as moving a table, pushing a vacuum cleaner, bowling or playing golf?

In the past four weeks, has your health limited you in lifting or carrying groceries?

In the past four weeks, has your health limited you in climbing several flights of stairs?

In the past four weeks, has your health limited you in climbing one flight of stairs?

In the past four weeks, has your health limited you in bending, kneeling or stooping?

In the past four weeks, has your health limited you in walking several blocks?

In the past four weeks, has your health limited you in walking one block?

In the past four weeks, has your health limited you in walking short distances (e.g. around your house)?

During the past four weeks, did you need help from another person to take a bath or shower?

During the past four weeks, did you need help from another person to get dressed?

During the past four weeks, did you need help from another person to use the toilet?

During the past four weeks, did you need help from another person to eat?

During the past four weeks, did you need help from another person to get in or out of bed?

During the past four weeks, have you been able to go shopping for groceries without help?

During the past four weeks, have you been able to prepare your own meals without help?

During the past four weeks, have you been able to do your own housework without help?

During the past four weeks, have you been able to do your own laundry without help?

During the past four weeks, have you been able to use public transportation or drive your own car?

How much pain have you had during the past four weeks?

During the past four weeks, how much has pain interfered with your normal activities?

How satisfied or dissatisfied are you with your relationships with family or friends?

How satisfied or dissatisfied are you with the amount of support you receive from family and friends?

During the past four weeks, did you feel that your family or friends would be around if you needed assistance?

During the past four weeks, did your physical health limit your ability to socialize with family or friends?

During the past four weeks, did your emotional health limit your ability to socialize with family or friends?

During the past four weeks, did you feel full of pep?

During the past four weeks, have you been nervous?

During the past four weeks, did you feel down in the dumps?

During the past four weeks, have you felt peaceful and content?

During the past four weeks, did you feel your life had purpose?

During the past four weeks, have you felt hopeful about the future?

During the past four weeks, have you worried about dying?

During the past four weeks, did you feel life was worthwhile?

During the past four weeks, did you feel in control of your life?

I spend time in activities that nourish my spiritual life.

I am not interested in activities that nourish my spiritual life.

I am satisfied with my spiritual life.

I feel that I am treated with dignity and respect.

How satisfied or dissatisfied are you with your living arrangements?

How satisfied or dissatisfied are you with the amount of privacy that you have?

How satisfied or dissatisfied are you with the choices you have (e.g. control over time and your daily activities)?