Quality of Life
Date Taken:
1. In the past 2 weeks, how would you rate your overall quality of life?
Very poor
Poor
Neither poor nor good
Good
Very good
2. In the past 2 weeks, how satisfied have you been with your physical health?
Very dissatisfied
Dissatisfied
Neither satisfied nor dissatisfied
Satisfied
Very satisfied
3. In the past 2 weeks, how satisfied have you been with your psychological health?
Very dissatisfied
Dissatisfied
Neither satisfied nor dissatisfied
Satisfied
Very satisfied
4. In the past 2 weeks, how satisfied have you been with your social relationships?
Very dissatisfied
Dissatisfied
Neither satisfied nor dissatisfied
Satisfied
Very satisfied
Submit
History
Date Taken:
Score
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