Date Entered_________ Staff Initials_________
COMBINE WHOQOL (WHO ver. A)
Center Participant # Participant Initials Week
Date
Staff ID
/
mo. da.
/
yr.
Instructions: The questions ask how you feel about your quality of life, health, or other areas of your life. Please answer all the questions. If you are unsure about which response to give to a question, please choose the one that appears most appropriate. This can often be your first response. Please keep in mind your standards, hopes, pleasures and concerns. We ask that you think about your life in the last two weeks. Please read each question, assess your feelings, and circle the number on the scale that gives the best answer for you for each question.
Very Poor 1. How would you rate your quality of life? 1
Poor
Neither poor nor good 3
Good
Very Good
Very Dissatisfied
Dissatisfied
Neither satisfied nor dissatisfied
Satisfied
Very satisfied
2. How satisfied are you with your health?
The following questions ask about how much you have experienced certain things in the last two weeks. Not at all 3. To what extent do you feel that physical pain prevents you from doing what you need to do? 4. How much do you need any medical treatment to function in your daily life? 5. How much do you enjoy life? 6. To what extent do you feel your life to be meaningful? 1 A little 2 A moderate Very much An extreme amount amount 3 4 5
1 1 1
2 2 2
3 3 3
4 4 4
5 5 5
WHO_5 (10/11/00)
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Center
Participant #
Participant Initials
Week
Date
Staff ID
/
mo. da.
/
yr.
Not at all Slightly A moderate Very much Extremely amount 7. How well are you able to concentrate? 8. How safe do you feel in your daily life? 9. How healthy is your physical environment? 1 1 1 2 2 2 3 3 3 4 4 4 5 5 5
The following questions ask about how completely you experienced or were able to do certain things in the last two weeks. Not at all 10. Do you have enough energy for everyday life? 11. Are you able to accept your bodily appearance? 12. Have you enough money to meet your needs? 13. How available to you is the information that you need in your day-to-day life? 14. To what extent do you have the opportunity for leisure activities? 1 1 1 1 1 A little Moderately 2 2 2 2 2 3 3 3 3 3 Mostly 4 4 4 4 4 Completely 5 5 5 5 5
Very Poor
Poor
Neither poor nor well 3
Well
Very Well
15. How well are you able to get around?
WHO_5 (10/11/00)
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Center
Participant #
Participant Initials
Week
Date
Staff ID
/
mo. da.
/
yr.
The following questions ask you to say how good or satisfied you have felt about various aspects of your life over the last two weeks.
Very Dissatisfied Dissatisfied Neither satisfied nor dissatisfied Satisfied Very satisfied
16. How satisfied are you with your sleep? 17. How satisfied are you with your ability to perform your daily living activities? 18. How satisfied are you with your capacity for work? 19. How satisfied are you with your abilities? 20. How satisfied are you with your personal relationships? 21. How satisfied are you with your sex life? 22. How satisfied are you with the support you get from your friends? 23. How satisfied are you with the conditions of your living place? 24. How satisfied are you with your access to health services? 25. How satisfied are you with your mode of transportation?
1 1 1 1 1 1 1 1 1 1
2 2 2 2 2 2 2 2 2 2
3 3 3 3 3 3 3 3 3 3
4 4 4 4 4 4 4 4 4 4
5 5 5 5 5 5 5 5 5 5
WHO_5 (10/11/00)
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