QOLIE-89

QOLIE-89







    1. In general, would you say your health is:

    2.On a scale of 0 to 10, how would you rate your quality of life?
    0: Worst Possible Quality of Life [as bad as or worse than being dead]
    10: Best Possible Quality of Life

    3.Compared to 1 year ago, how would you rate your health in general now?

    The following questions (4 -13) are about activities you might do during a typical day. Does your health limit you in these activities? If so, how much?

    4.Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports

    5.Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf.

    6.Lifting or carrying groceries

    7.Climbing several flights of stairs

    8.Climbing one flight of stairs

    9.Bending, kneeling, or stooping

    10.Walking more than one mile

    11.Walking several blocks

    12.Walking one block

    13.Bathing or dressing yourself


    During the past 4 weeks, have you had any of the following difficulties with your regular daily activities or work as a result of any physical problems? (Please indicate YES or NO)

    14.Cut down on the amount of time you spent on work or other activities

    15.Accomplished less than you would like

    16.Were limited in the kind of work or other activities you do

    17.Had difficulty performing the work or other activities you do (for example, it took extra effort)

    18.Did you work or other activities less carefully than usual

    19.Cut down on the amount of time you spent on work or other activities

    20.Accomplished less than you would like

    21.Were limited in the kind of work or other activities you do

    22.Had difficulty performing the work or other activities you do (for example, it took extra effort)

    23.Did you work or other activities less carefully than usual

    24.How much bodily pain have you had during the past 4 weeks?

    25.During the past 4 weeks, how much did bodily pain interfere with your normal work (including both work outside the home and housework)?

    26.During the past 4 weeks, to what extent have your physical health or emotional problems interfered with your normal social activities with family, neighbours or groups?


    How much of the time during the past 4 weeks…

    27.Did you feel full of pep?

    28.Have you been a very nervous person?

    29.Have you felt so down in the dumps that nothing could cheer you up?

    30. Have you felt calm and peaceful?

    31.Did you have a lot of energy?

    32.Have you felt downhearted and blue?

    33.Did you feel worn out?

    34.Have you been a happy person?

    35.Did you feel tired?


    36.Has your epilepsy limited your social activities (such as visiting with friends or close relatives)?

    37.Have you had difficulty concentrating and thinking?

    38.Did you have trouble keeping your attention on an activity for long?

    39.Were you discourage by problems related to your health?

    40.Have you worried about having another seizure?

    41.Did you have difficulty reasoning and solving problems (such as making plans, making decisions, learning new things)?

    42.Were you discourage by your epilepsy-related problems?

    43.Have your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)?

    44.I seem to get sick (any kind of sickness) a little easier than other people

    45.I am as healthy as anybody I know

    46.I expect my health to get worse

    47.My health is excellent

    48.When there is an illness going around, I usually catch it

    49.How has the QUALITY OF YOUR LIFE been during the past 4 weeks (that is, how have things been going for you)?

    The following question is about MEMORY
    50.In the past 4 weeks, have you had any trouble with your memory?


    51.Names of people

    52.Where you put things?

    53.Things people tell you

    54.Things you read hours or days before


    55.Finding the correct word

    56.Understanding what others are saying in conversation

    57.Understanding directions

    58.Understanding what you read

    59.Writing

    60.Concentrating on conversations

    61.Concentrating on a task or job

    62.Concentrating on reading

    63.Concentrating on doing one thing at a time

    64.How often do you feel you react slowly to things that are said or done?

    65.Working

    66.Friendships and relationships (romantic)

    67.Leisure time (such as hobbies, going out)

    68.Driving

    69.How fearful are you of having a seizure during the next month?

    70.Do you worry about hurting yourself during a seizure?

    71.How worried are you about embarrassment or other social problems resulting from having a seizure during the next month?

    72.How worried are you that medications you are taking will be bad for you if taken for a long time?

    73.How well do you do with complicated projects that require organisation or planning?


    74.Seizures

    75.Memory difficulties

    76.Driving limitations

    77.Work limitations

    78.Social limitations

    79.Physical effects of antiepileptic medication

    80.Mental effects of antiepileptic medication

    81.The amount of togetherness you have with your family and/or friends

    82.The support and understanding your family and/or friends give each other

    83.The amount you talk things over with your family and/or friends

    84.Overall, how satisfied were you with your sexual relations during the past 4 weeks?

    85.How limited are your social activities compared with others your age because of your epilepsy or epilepsy-related problems?

    86.During the past 4 weeks, was someone available to help you if you needed and wanted help?

    87.How much of the time during the past 4 weeks did you feel left out?

    88.During the past 4 weeks, how often did you feel isolated from others?

    89.How good or bad do you think your health is? On a scale of 0 to 100, where 0 = the worst imaginable state and 100 = the best imaginable state. Please consider your epilepsy as part of your health when you answer this question.

    THANK YOU FOR COMPLETING THIS QUESTIONNAIRE

    STAFF USE ONLY
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