Wisconsin Quality of Life Provider Questionnaire

Wisconsin Quality of Life Provider Questionnaire
W-QLI Provider Questionnaire
Marion A. Becker‚ Bret R. Shaw‚ Lisa M. Reib (1996)
It’s not complete instrument: please see source.
Client’s date of birth and Sex
·         During the past four weeks‚ this person has: (Check one)
·         What sort of work is this person generally capable of (even if unemployed‚ retired‚ or doing unpaid domestic duties)? (Check one)
·         In the past four weeks‚ would you say that this person’s overall psychological health has been: (Check one)
·         During the past four weeks‚ this person has: (Check one)
·         Does this person have any significant medical illness or physical impairments other than mental illness? No Yes (Specify: ________________________________________)
·         How much of a physical problem do you think this person has from antipsychotic medication side effects? Severe‚ Moderate‚ Mild‚ Slight‚ None
·         During the past four weeks‚ this person has: (Check one)
·         Does this person attend any social organization (e.g.‚ church‚ club or interest group but excluding psychiatric therapy groups)? (Check one) Frequently‚ Occasionally‚ Rarely‚ Never
·         Does this person generally make and keep up friendships? (Check one)
·         How would you describe the quality of this person’s relationship with his/her family? (Check one)
·         Is this person paid for working or attending school? Yes No
·         How does this person feel about the amount of money s/he has? (Check one)
·         How important to this person is money? (Check one)
·         How often does lack of money keep this person from doing what s/he wants to do? (Check one) Never‚ Sometimes‚ Frequently‚ Almost‚ always
·         During the past four weeks this person has: (Check one)
·         Does this person generally have any difficulty with initiating and/or responding to conversation? No difficulty‚ Slight difficulty‚ Moderate Difficulty‚ Extreme Difficulty
·         Is this person generally well groomed (e.g.‚ neatly dressed‚ hair combed? Well Groomed‚ Moderately groomed‚ well groomed‚ Poorly Groomed‚ Extremely poorly
·         Does this person generally neglect his/her physical health? No neglect‚ Slight neglect‚ Moderate neglect‚ Extreme neglect
·         Does this person generally maintain an adequate diet? No problem‚ Slight problem‚ Moderate problem‚ Extreme problem
·         Does this person generally look after and take his/her own prescribed medication (or attend to prescribed injections on time) without reminding? No Meds‚ Reliable with medication‚ Slightly unreliable‚ Moderately unreliable‚ Extremely unreliable
·         Is this person generally inactive (e.g.‚ spends most of the time sitting or standing around doing nothing)? Appropriately active‚ Slightly inactive‚ Moderately inactive‚ Extremely inactive
·         Does this person generally have definite interests (e.g.‚ hobbies‚ sports‚ activities) in which s/he is involved regularly? Considerable involvement‚ Moderate involvement‚ Some involvement‚ Not involved at all
·         Can this person generally prepare (if needed) his/her own food or meals? Quite capable of preparing‚ Slight limitations‚ Moderate limitations‚ Totally incapable of preparing
·         Can this person generally budget (if needed) to live within his/her own means? Quite capable of budgeting‚ Slight limitations‚ Moderate limitations‚ Totally incapable of budgeting
·         Does this person have habits or behaviors that people find offensive? Not at all‚ Rarely‚ Occasionally‚ Often
·         During the past four weeks‚ this person has: (Check one)
·         Does this person behave dangerously because of confusion or preoccupation (e.g.‚ ignoring traffic when crossing the road)? (Check one)
·         Please complete the following 24-item version of the Brief Psychiatric Rating Scale. The scale should be completed to reflect the person’s current condition. Using the scale value below‚ enter the number in the box that best describes the person’s present condition.
1=No problem‚ 2=Very mild‚ 3=Mild‚ 4=Moderate‚ 5=Moderately severe‚ 6=Severe‚ 7=Extremely severe
a.    Somatic Concern – preoccupation with physical health‚ fear of physical illness
b.    Disorientation – confusion regarding person‚ place or time
c.    Anxiety – worry‚ fear‚ over concern for present or future
d.    Conceptual Disorganization – thought process confused‚ disconnected‚ disorganized‚ disrupted
e.    Depressive mood – sorrow‚ sadness‚ despondency‚ pessimism
f.     Excitement – heightened emotional tone‚ increased reactivity‚ impulsivity
g.    Guilt feelings – self-blame‚ shame‚ remorse for past behavior
h.    Motor Retardation – slowed‚ weakened movements or speech‚ reduced body tone
i.      Hostility – animosity‚ contempt‚ belligerence‚ disdain for others
j.     Blunted Affect – reduced emotional tone‚ reduction in normal intensity of feelings‚ flatness
k.    Suspiciousness – mistrust‚ belief others harbor malicious or discriminatory intent
l.      Tension – physical and motor manifestations or nervousness‚ hyperactivity
m. Unusual Thought Content – unusual‚ odd‚ strange‚ bizarre thought content
n.    Mannerisms and Posturing – peculiar‚ bizarre‚ unnatural motor behavior
o.    Grandiosity – exaggerated self-opinion‚ arrogance‚ conviction of unusual power of abilities
p.    Uncooperativeness – resistance‚ guardedness‚ rejection of authority
q.    Hallucinatory Behavior – perceptions without normal external stimulus correspondence
r.     Bizarre Behavior – reports of odd‚ unusual‚ or psychotically criminal behavior
s.    Emotional Withdrawal – lack of spontaneous interaction‚ isolation‚ deficiency in relating to others
t.     Elated Mood – euphoria‚ optimism that is out of proportion to circumstances
u.    Suicidality – expressed desire‚ intent‚ or actual actions to harm or kill self
v.    Motor Hyperactivity – frequent movements and/or rapid speech
w.   Self-Neglect – hygiene‚ appearance‚ or eating below social standards
x.    Distractibility – speech and actions interrupted by minor external stimuli or hallucinations/delusions
What are your goals for the mental health treatment of this person? Please list up to 3 goals:
Goal 1: ______________________________________________
How important is this goal? Not at all important 1 2 3 4 5 6 7 8 9 10 Extremely important
To what extent has this goal been achieved? Not at all achieved 1 2 3 4 5 6 7 8 9 10Completely achieved
Goal 2: _______________________________________
How important is this goal? Not at all important 1 2 3 4 5 6 7 8 9 10 Extremely important
To what extent has this goal been achieved? Not at all achieved 1 2 3 4 5 6 7 8 9 10Completely achieved
Goal 3: _______________________________________
How important is this goal? Not at all important 1 2 3 4 5 6 7 8 9 10 Extremely important
To what extent has this goal been achieved? Not at all achieved 1 2 3 4 5 6 7 8 9 10Completely achieved
Please check a 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
·         How confident are you that your rating of the person’s quality of life is accurate? (Check one)
·         What is this person’s primary psychiatric diagnosis? ________________________________
·         How effective do you think the antipsychotic medication is in treating this person’s mental illness? Not at all effective‚ Slightly effective‚ Mildly effective‚ Moderately effective‚ Extremely effective
·         In the past four weeks‚ did this person take his/her antipsychotic medications as prescribed? (Check one)
·         In the past four weeks‚ how much assistance did this person receive to take his/her prescribed medication? (Check one)
·         Does this person use alcohol or other drugs? (NOTE: If you mark ‘Not at all’‚ please skip the next question.)
·         To what extent does this person’s alcohol or other drug use concern you? (Check one)
·         Does this person get into trouble with the police? (Check one)
Which of the following factors do you think are most important in maintaining your client’s quality of life?
Not important‚ Slightly important‚ Moderately important‚ Very important‚ Extremely important
a.    Work‚ school or other occupational activities
b.    Feelings about him/herself
c.    His/her physical health
d.    Friends‚ family‚ people s/he spends time with
e.    ha‎ving enough money
f.     Ability to take care of him/herself
g.    Mental health
h.    Other‚ please specify: _________________________
Is there anything else you would like us to know?
Cronbach’s Alpha: Activities of Daily Living .8371‚ Money / Economics .6907‚ Social Relations / Support .6994‚ Symptoms .8536.
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]