Wisconsin Quality of Life Caregiver Questionnaire
Marion A. Becker‚ Bret R. Shaw‚ Lisa M. Reib (1996)
[email protected]
It’s not complete instrument: please see source.
BACKGROUND INFORMATION (sample)
1. Please list members residing in your household: Name (First names only)‚ Relationship to client
2. Do you have a job at the present time? Yes No (if no‚ please skip to #5)
3. How many hours a week do you work or go to school? _____ hours per week
4. What is your occupation? _________________________
5a. Who was your relative/friend/neighbor living with when he/she first became ill? (Check all that apply): alone‚ with parents‚ friend/roommate‚ with significant other/spouse‚ with children‚ other‚ please specify …
5b. Where was you neighbor/relative friend living when he/she first became ill? (Check one)
6. How old was your relative/friend/neighbor when he/she first became ill? _______years
7a. Who is your relative/friend/neighbor living with now? (Check one) …
7b. Where is you relative/friend/neighbor living now? (Check one)
8. When was the last time the patient spent more than 7 consecutive overnights in your household?
9. In the time that you have been involved with the patient‚ how many times has he/she been hospitalized? None ______ # times
10. What services has the patient received during the past 6 months? Don’t know
Please check all that apply.
Community Support Program/
· Assertive Case Management with Regular Community Outreach
· Job/Vocational Training
· Individual Psychiatrist Appointments
· Medication Group
· Case Management
· Individual Therapy other than Case Manager
· Groups including Living Skills‚ Social‚ Recreational‚ and Therapy groups
· Day Treatment
· General Medical Health
· Housing Support
· Any Other Services?
· Please Specify: _________________________________
SERVICES
11. People are often required to talk with mental health professionals in trying to help their relative/friend/neighbor with mental illness. To what extent do the following statements reflect experiences you have had in getting treatment for your relative/friend/neighbor?
For each statement below‚ please tell us whether you strongly agree‚ agree‚ have no opinion‚ disagree‚ strongly disagree with it or don’t know. Under each statement please check the corresponding box that best reflects your feelings.
a. The health care professionals that I have dealt with feel that I can play an important role in the treatment process. Strongly Know/ Agree Apply‚ Agree‚ No Opinion‚ Disagree‚ strongly Disagree‚ Don’t Doesn’t
b. The health care professionals that I have dealt with have given me as much information as I have needed. Strongly Know/ Agree Apply‚ Agree‚ No Opinion‚ Disagree‚ strongly Disagree‚ Don’t Doesn’t
c. I am comfortable questioning health care professionals about advice they give me. Most of Know/ the time Apply‚ Some of the time‚ No Opinion‚ Rarely‚ Never‚ Don’t Doesn’t
d. I would like to have more say than I do now about the services and medication my relative/friend/neighbor receives. Strongly Know/ Agree Apply‚ Agree‚ No Opinion‚ Disagree‚ Strongly Disagree‚ Don’t Doesn’t
e. Sometimes I feel that the health care professionals that I work with do not understand the problems people face in caring for a person with a mental illness. Strongly Know/ Agree Apply‚ Agree‚ No Opinion‚ Disagree‚ Strongly Disagree‚ Don’t Doesn’t
f. I often wish that I knew more about mental illness when I talk with health care professionals. Strongly Know/ Agree Apply‚ Agree‚ No Opinion‚ Disagree‚ Strongly Disagree‚ Don’t Doesn’t
g. I am comfortable in getting a second opinion when I have questions about advice I get from a health care professional. Strongly Know/ Agree Apply‚ Agree‚ No Opinion‚ Disagree‚ Strongly Disagree‚ Don’t Doesn’t
12. In general‚ how many contacts does your relative/friend/neighbor have with members of your household? Please fill in the blanks as appropriate.
Patient resides with you. Yes No; If Yes‚ patient has spent _____ overnights away.
· I and other members of my household and the client have seen each other ___times in the past month
· I and other members of my household and the client have talked on the telephone __times in the past month.
· I and other members of my household and the client have corresponded in the past month. Yes No
· No contact in the past two months Yes No
· Other‚ please specify: _________________________________
13. In the past six months have you or any other member of your household had any meetings‚ any visits or phone calls to or from individuals who are treating the patient? (Doctors‚ Social workers‚ Psychologists‚ Counselors‚ Welfare workers).
· If Yes‚ please complete the following information:
Number‚ Agencies involved
Personal Visits ______ _______________
Phone Contacts ______ _______________
Other: ______ _______________
· Were any of these contacts of any help to you? Yes No‚ please specify why not: _________________________________________
· If no‚ i.e.‚ you haven’t had contact‚ would you like to have had contact with any of these people? Yes No
FAMILY ASSISTANCE
14. Family and friends often take on responsibilities to provide care and support for a person with mental illness. During the past four weeks how much support or supervision did you give to your relative/friend/neighbor in dealing with these particular problems/difficulties shown below and how did you feel about giving this support?
a. Maintaining personal hygiene. None ‚ Little‚ Some‚ Much
How did you feel about giving such support? Satisfled‚ Accepted‚ Dissatisfied
b. Taking prescribed medication. None ‚ Little‚ Some‚ Much
How did you feel about giving such support? Satisfled‚ Accepted‚ Dissatisfied
c. Preparing meals. None ‚ Little‚ Some‚ Much
How did you feel about giving such support? Satisfled‚ Accepted‚ Dissatisfied
d. Getting up and getting dressed. None ‚ Little‚ Some‚ Much
How did you feel about giving such support? Satisfled‚ Accepted‚ Dissatisfied
e. Doing household chores. None ‚ Little‚ Some‚ Much
How did you feel about giving such support? Satisfled‚ Accepted‚ Dissatisfied
f. Managing money. None ‚ Little‚ Some‚ Much
How did you feel about giving such support? Satisfled‚ Accepted‚ Dissatisfied
g. Shopping for food‚ clothing‚ etc. None ‚ Little‚ Some‚ Much
How did you feel about giving such support? Satisfled‚ Accepted‚ Dissatisfied
h. Making use of leisure time. None ‚ Little‚ Some‚ Much
How did you feel about giving such support? Satisfled‚ Accepted‚ Dissatisfied
15. During the past four weeks‚ how much support or supervision did you give to help the patient control (overcome) the particular behaviors shown below?
a. Socially embarrassing behavior None‚ Little‚ Some‚ Much
How did you feel about giving such support? Satisfled‚ Accepted‚ Dissatisfied
b. Attention-seeking behavior None‚ Little‚ Some‚ Much
How did you feel about giving such support? Satisfled‚ Accepted‚ Dissatisfied
c. Inappropriate sexual behavior None‚ Little‚ Some‚ Much
How did you feel about giving such support? Satisfled‚ Accepted‚ Dissatisfied
d. Threatening or violent behavior None‚ Little‚ Some‚ Much
How did you feel about giving such support? Satisfled‚ Accepted‚ Dissatisfied
e. Talk or threats of suicide None‚ Little‚ Some‚ Much
How did you feel about giving such support? Satisfled‚ Accepted‚ Dissatisfied
f. Disturbing behavior at night None‚ Little‚ Some‚ Much
How did you feel about giving such support? Satisfled‚ Accepted‚ Dissatisfied
16. What is the hardest part in giving support to your relative/friend/neighbor? Please list the three hardest things to you‚ in order from most difficult to least difficult.
1.
2.
3.
17. Are there things that you enjoy about supporting your relative/friend/neighbor? Please explain: ……………………………….
LIFE ACTIVITIES AND GOALS (sample)
Now we are interested in knowing about your relative/friend/neighbor’s abilities during the past four weeks.
18. ACTIVITY During the past four weeks‚ my relative/friend/neighbor has: (Check one)
19. DAILY LIVING During the past four weeks‚ my relative/friend/neighbor has: (Check one)
20. HEALTH During the past four weeks‚ my relative/friend/neighbor has: (Check one)
21. SUPPORT During the past four weeks‚ my relative/friend/neighbor has: (Check one)
22. OUTLOOK During the past four weeks‚ my relative/friend/neighbor has: (Check one)
23. From your perspective‚ what do you think are the important treatment goals for your relative/friend/neighbor?
Goal 1: _________________________________
· How important is this goal to your relative/friend/neighbor? Not at all important 1 2 3 4 5 6 7 8 9 10 Extremely Important
· To what extent has your relative/friend/neighbor achieved this goal? Not at all achieved 1 2 3 4 5 6 7 8 9 10 Completely achieved
Goal 2:__________________________________________
· How important is this goal to your relative/friend/neighbor? Not at all important 1 2 3 4 5 6 7 8 9 10 Extremely Important
· To what extent has your relative/friend/neighbor achieved this goal? Not at all achieved 1 2 3 4 5 6 7 8 9 10 Completely achieved
Goal 3: ______________________________________
· How important is this goal to your relative/friend/neighbor? Not at all important 1 2 3 4 5 6 7 8 9 10 Extremely Important
· To what extent has your relative/friend/neighbor achieved this goal? Not at all achieved 1 2 3 4 5 6 7 8 9 10 Completely achieved
24. Please check a box below to indicate your rating of your relative/friend/neighbor’s quality of life during the past four weeks.
Lowest quality means your relative/friend/neighbor’s life is as bad as it could be.
Highest quality means your relative/friend/neighbor’s life is the best it could be.
LOWEST QUALITY 1 2 3 4 5 6 7 8 9 10HIGHEST QUALITY
· If your relative/friend/neighbor’s quality of life is less than he/she hoped for‚ how hopeful are you that he/she will eventually achieve his/her desired quality of life? (Check one)
· How much control do you feel your relative/friend/neighbor has over the important areas of his/her life? (Check one)
25. How confident are you that your rating of your relative/friend/neighbor’s quality of life is accurate? Please check the appropriate box.
26. Which of the following factors do you think are most important in determining your relative/friend/neighbor’s quality of life?
Not important‚ Slightly important‚ Mildly important‚ Moderately important‚ Extremely important
· Work‚ school or other occupational activities
· Your relative/friend/neighbor’s feelings about him/herself
· Your relative/friend/neighbor’s physical health
· Friends‚ family‚ people your relative/friend/neighbor spends time with
· having enough money
· Your relative/friend/neighbor’s ability to take care of him/herself
· Mental health
· Other‚ please specify:
27. Have there been any important factors which would influence your relative/friend/neighbor’s quality of life (i.e.‚ deaths in the family‚ serious physical illness‚ accidents)? Please briefly explain.
28. Is there anything else you would like to tell us?
29. What is the most important thing that now needs to be done for your relative/friend/neighbor?
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]