It’s not complete instrument: please see source.
PHYSICAL HEALTH (sample)
The following questions refer to your client’s health status. Please check (3) the most appropriate answer.
· In general‚ would you say your client’s physical health is: Poor‚ Fair‚ Good‚ Very Good‚ Excellent
· Compared to one year ago‚ how would you rate your client’s health in general now? Much Worse‚ Somewhat Worse‚ About the Same‚ Somewhat Better‚ Much Better
Please choose the answer that best describes how true or false the following statements are for your client.
· Compared to others the age of my client his/her health is as good as can be expected. Definitely False‚ Mostly False‚ Not Sure‚ Mostly True‚ True Definitely
· I expect this client’s health to get worse. Definitely False‚ Mostly False‚ Not Sure‚ Mostly True‚ True Definitely
· Does your client take medication for his/her health? Yes No
If yes‚ how many different medications does he/she take? ____
· (Include all medications; over the counter‚ prescribed‚ herbal‚ etc.)
YES‚ NO
· Does your client require help in taking his/her medications correctly?
· Is your client bothered by side effects from his/her medications?
During the past four weeks‚ have your client’s activities been limited in any of the following ways due to problems with his/her physical health?
Yes; completely‚ Yes; limited a lot‚ Yes; limited some‚ Yes; limited a little‚ No; not limited
· Limited the kind she could do? of activities he/
· Limited the amount of time he/she could do other activities he/she would like to do?
· Limited him/her in performing self-care?
The following questions are about activities your client might do on a typical day. In the past four weeks‚ has your client’s health limited him/her in any of the following activities?
All Days‚ Most Days‚ Some Days‚ Few Days‚ No Days
· Moderate Activities‚ such as moving a table‚ pushing a vacuum cleaner‚ bowling or playing golf.
· Lifting or carrying groceries.
· Climbing several flights of stairs.
· Climbing one flight of stairs.
· Bending‚ kneeling or stooping.
· Walking several blocks.
· Walking one block.
· Walking short distances. (e.g. around his/her house)
SELF-CARE
These questions refer to self-care tasks. Please check (x) the most appropriate answer.
During the past four weeks…
All Days‚ Most Days‚ Some Days‚ Few Days‚ No Days
· Did your client need help from another person to take a bath or shower?
· Did your client need help from another person to get dressed?
· Did your client need help from another person to use the toilet?
· Did your client need help from another person to eat?
· Did your client need help from another person to get in or out of bed?
These questions refer to household tasks. Please check (3) the most appropriate answer.
During the past four weeks…
All Days‚ Most Days‚ Some Days‚ Few Days‚ No Days
· Has your client been able to go shopping for groceries without help?
· Has your client been able to prepare his/her own meals without help?
· Has your client been able to do his/her own housework without help?
· Has your client been able to do his/her own laundry without help?
· Has your client been able to use public transportation or drive his/her own car?
PAIN AND SYMPTOMS
· How much pain has your client had during the past four weeks (check one)?
· During the past four weeks how much has pain interfered with your client’s normal activities weeks (check one)?
· Does your client take pain medication? Yes‚ No
If yes: Is your client’s pain controlled by the medication he/she takes weeks (check one)?
· If your client’s pain is not controlled by medication‚ how is it controlled? -–––––- Pain can’t be controlled
SOCIAL RELATIONS / SUPPORT
· During the past four weeks‚ your client has: (Check one)
· How would you describe the quality of your client’s relationship with his/her family? (Check one)
PSYCHOLOGICAL WELL-BEING
· In the past four weeks would you say that your client’s overall psychological health has been: Poor‚ Fair‚ Good‚ Very Good‚ Excellent
· During the past four weeks‚ your client has: (check one)
· During the past four weeks‚ has your client experienced a major loss? Yes‚ No
Please indicate below if during the past four weeks‚ your client’s activities have been limited in any of the following ways due to emotional difficulties.
Yes; completely‚ Yes; limited a lot‚ Yes; limited some‚ Yes; limited a little‚ No; not limited
· Limited the kind of activities your client could do?
· Limited the amount of time your client could do activities he/she would like to do?
· Limited your client in performing self-care or attend social activities?
To what extent is your client experiencing difficulty in the area of:
All Days‚ Most Days‚ Some Days‚ Few Days‚ No Days
· Managing day-to-day life (making decisions‚ handling money)?
· Getting enough sleep?
· Maintaining an adequate diet?
· Concentration‚ memory or confusion?
· Depression‚ hopelessness?
· Sexual activity?
· Mood swings?
· Drinking alcoholic beverages?
· Misusing drugs (including prescription drugs)?
· Please check the box below to indicate your rating of this person’s quality of life during the past four weeks. Lowest quality means things are as bad as they could be. Highest quality means things are the best they could be. LOWEST QUALITY 1 2 3 4 5 6 7 8 9 10 HIGHEST QUALITY
PERSONAL GOALS
Please list below the three most important goals for improving this client’s life.
Goal 1: _________________________________________
· To what extent has this goal been acheived? Not at all achieved 1 2 3 4 5 6 7 8 9 10 Completely achieved
Goal 2: ________________________________________
• To what extent has this goal been acheived? Not at all achieved 1 2 3 4 5 6 7 8 9 10 Completely achieved
Goal 3: ________________________________________
• To what extent has this goal been acheived? Not at all achieved 1 2 3 4 5 6 7 8 9 10 Completely achieved
This instrument can be found at: http://wqli.fmhi.usf.edu/wqli-instruments/
If you have any questions about this questionnaire‚ please call or write Marion Becker‚ Ph.D.‚ University of South Florida‚ Department of Community Mental Health‚ 13301 Bruce B. Downs Blvd.‚ MHC 1423‚ Tampa‚ Florida 33612-3899 Telephone: (813)974-7188 Fax: (813)974-6469 E-Mail: [email protected]