Wisconsin Quality of Life Client Questionnaire
Marion A. Becker‚ Bret R. Shaw‚ Lisa M. Reib (1996)
WISCONSIN QUALITY OF LIFE CLIENT QUESTIONNAIRE
It’s not complete instrument: please see source.
BACKGROUND INFORMATION (sample)
date of birth‚ Sex‚ highest school grade‚ current relationship/marital status‚ source of income‚ racial/ethnic background‚ During the past four weeks‚ you lived‚ Who would you like live with?‚ During the past four weeks‚ you lived primarily?‚ Where would you like to live?
SATISFACTION LEVEL (sample)
Very dissatisfied‚ Moderately dissatisfied‚ A little dissatisfied‚ Neither satisfied or dissatisfied‚ A little satisfied‚ Moderately satisfied‚ Very satisfied
a. How satisfied or dissatisfied are you when you are alone?
b. How satisfied or dissatisfied are you with your housing?
c. How satisfied or dissatisfied are you with your neighborhood as a place to live in?
d. How satisfied or dissatisfied are you with the food you eat?
e. How satisfied or dissatisfied are you with the clothing you wear?
f. How satisfied or dissatisfied are you with the mental health services you use?
g. How satisfied or dissatisfied are you with your access to transportation?
h. How satisfied or dissatisfied are you with your sex life?
i. How satisfied or dissatisfied are you with your personal safety?
j. We have asked how satisfied you are with different parts of your life. Now we would like to know how important each of these aspects of your life are.
Not at all important‚ Slightly important‚ Moderately important‚ Very important‚ Extremely important‚
a. How important to you is the way you spend your time?
b. How important is it to feel comfortable when alone?
c. How important is your housing?
d. How important is your neighborhood as a place to live in?
e. How important to you is the food you eat?
f. How important to you is the clothing you wear?
g. How important to you are the mental health services you use?
h. How important to you is your access to transportation?
i. How important to you is your sex life?
j. How important to you is your personal safety?
ACTIVITIES AND OCCUPATIONS (sample)
a. During the past four weeks‚ you have: (Check one) …
b. What is your main activity? (Check one)…
c. How satisfied or dissatisfied are you with the main activitity that you do? (Check one)…
d. Do you feel that you are engaged in activities: (Choose one): Less than you would like‚ More than you would like‚ As much as you want
e. What would you like to have as your main activity?
PSYCHOLOGICAL WELL-BEING (sample)
Now we would like to know how you feel about things in your life. For each of the following questions‚ check the boxes that best describe how you have felt in the past four weeks. YES or NO
a. Pleased about having accomplished something?
b. Very lonely or remote from other people?
c. Bored?
d. That things went your way?
e. So restless that you couldn’t sit long in a chair?
f. Proud because someone complimented you on something you had done?
g. Upset because someone criticized you?
h. Particularly excited or interested in something?
i. Depressed or very unhappy?
j. On top of the world?
k. In the past four weeks‚ would you say that your mental health has been: Poor‚ Fair‚ Good‚ Very good‚ Excellent
SYMPTOMS/OUTLOOK (sample)
a. During the past four weeks‚ you have: (Check one)…
b. There are many aspects of emotional distress including feelings of depression‚ anxiety‚ hearing voices‚ etc. In the past four weeks‚ how much distress have these symptoms caused you?: (Check one)…
In the past four weeks: Never‚ Occasionally‚ Frequently‚ Most of the time‚ Constantly
c. How much has feelings of depression‚ anxiety interfered‚ etc. with your daily life?
d. Have you felt like killing yourself?
e. Have you felt like harming others?
PHYSICAL HEALTH (sample)
a. In the past four weeks‚ you would best describe your physical health as: Poor‚ Fair‚ Good‚ Very good‚ Excellent
b. How do you feel about your physical health? (Check one)…
c. How important to you is your physical health? (Check one)…
d. Are you currently taking psychiatric medications? Yes No (If no‚ go to next page)
e. If you are currently taking psychiatric medications‚ do you take them as prescribed? (Check one)…
f. If you are currently taking psychiatric medications‚ do you take them as prescribed? (Check one)‚ None; Slight; Mild; Moderate; Severe
g. If you take medications for mental health problems‚ do you feel the medication helps control your symptoms? Not at all‚ Some‚ A fair amount‚ Quite a bit‚ Eliminates all Symptoms
h. How do you feel about taking your psychiatric medications? (Check one)…
ALCOHOL & OTHER DRUGS
a. Over the past four weeks‚ have you drank any alcohol? Yes No
b. If yes‚ on how many days have you had any alcohol to drink over the past four weeks? _____ (number of days)
c. What do you think about your alcohol use? (Check one)…
d. Over the past four weeks‚ have you used any street drugs (cocaine‚ marijuana‚ heroin‚ speed‚ LSD‚ etc.)? Yes No
e. If yes‚ on how many days have you had any alcohol to drink over the past four weeks? _____ (number of days)
f. What do you think about your drug use? (Check one)…
SOCIAL RELATIONS / SUPPORT
Very dissatisfied‚ Moderately dissatisfied‚ A little dissatisfied‚ Neither satisfied or dissatisfied‚ A little satisfied‚ Moderately satisfied‚ Very Satisfied‚
a. How satisfied or dissatisfied are you with the number of friends you have? No friends
b. How satisfied or dissatisfied are you with how you get along with your friends?
c. How satisfied or dissatisfied are you with your relationship with your family? No family
d. If you live with others‚ how satisfied or dissatisfied are you with the people with whom you live? Live alone
e. How satisfied or dissatisfied are you with how you get along with other people?
f. How many people do you count as your friends? none 1-2 3-5 over 5
IMPORTANCE LEVEL
Not at all important‚ Slightly important‚ Moderately important‚ Very important‚ Extremely important
a. How important is it to have an adequate number of friends?
b. How important is it to get along with your friends?
c. How important are family relationships?
d. If you live with others‚ how important are the people with whom you live?
e. How important is it to get along with others?
f. During the past four weeks‚ you have (check one)…
MONEY
a. Are you paid for working or attending school? Yes No
b. How do you feel about the amount of money you have? (check one)…
c. How satisfied are you about the amount of control you have over your money? (check one)…
d. How important to you is money? (check one)…
e. How important is it to you to have control over your money? (Check one)…
f. How often does lack of money keep you from doing what you want to do? (Check one)…
ACTIVITIES OF DAILY LIVING
a. Below are activities that you may have participated in recently. Please check YES or NO to indicate whether you have done the activity in the past four weeks.
Gone to a restaurant or coffee shop
Gone shopping
Gone for a ride in a bus or car
Prepared a meal
Cleaned the room/apartment/home
Done the laundry
b. During the past four weeks you: have been able to do most things on your own (such as shopping‚ getting around town‚ etc.); have needed some help in getting things done; have had trouble getting tasks done‚ even with help
c. In the past four weeks‚ how often have you had any problems with personal grooming (e.g. taking showers‚ brushing your teeth)? Never‚ Sometimes‚ Frequently Almost always
GOAL ATTAINMENT
a. What do you hope to accomplish as a result of your mental health treatment? Please write below up to 3 goals:
Goal 1: _____________________________________________________
How important is this goal to you? Please check the box below to indicate how important this goal is to you. (NR = No Response)? Not at all important 1 2 3 4 5 6 7 8 9 10 Extremely important‚ NR
To what extent have you achieved this goal? Please check the box below to indicate the extent to which you have achieved this goal. Not at all achieved 1 2 3 4 5 6 7 8 9 10 Completely achieved‚ NR
Goal 2: ______________________________________________________
How important is this goal to you? Not at all important 1 2 3 4 5 6 7 8 9 10 Extremely important‚ NR
To what extent have you achieved this goal? Not at all achieved 1 2 3 4 5 6 7 8 9 10 Completely achieved‚ NR
Goal 3: ______________________________________________
How important is this goal to you? Not at all important 1 2 3 4 5 6 7 8 9 10 Extremely important‚ NR
To what extent have you achieved this goal? Not at all achieved 1 2 3 4 5 6 7 8 9 10 Completely achieved‚ NR
b. Below are activities that you may have participated in recently. Please check Yes or No to indicate whether you have done the activity in the past four weeks.
Gone for a walk
Gone to a social group
Gone to a movie or play
Read a magazine or newspaper
Watched TV
Gone to church‚ synagogue‚ mosque
Played cards
Listened to a radio
Played a sport
Gone to a library
c. Please check the box below to indicate how you feel about your 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
d. If your quality of life is less than you hope for‚ how hopeful are you that you will eventually achieve your desired quality of life? (Check one) Not at all‚ Somewhat‚ Moderately‚ Very
e. How much control do you feel you have over the important areas of your life? (Check one)
f. How important are each of the following factors in determining your quality of life? Not at all important‚ Slightly important‚ Moderately important‚ Very important‚ Extremely important
Work‚ school or other occupational activities
Your feelings about yourself
Your physical health
Friends‚ family‚ people you spend time with
having enough money
Ability to take care of yourself
Your mental health
Other‚ please specify: _______________________
Is there anything else you would like us to know?
Cronbach’s Alpha: Social Relations / Support .7585‚ Money / Economics .6854‚ Activities of Daily Living .6697‚ Occupational Activities .9343‚ Psychological Well Being .7938‚ Symptoms .7707‚ Physical Health .7446‚ Life Satisfaction .8250.
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]
Becker‚ Marion A.; Reib‚ Lisa M.; & Shaw‚ Bret R. (1996). Quality of Life Assessment Manual. University of Wisconsin—Madison Mental health services. [Place of publication not identified] : [publisher not identified]