Salud Integral Treatment procedures

Quality of Life Questionnaire

Please complete the questionnaire below as required.
(Best completed in Google Chrome or Firefox Browser, you may get errors if viewed and completed in Internet Explorer Browser.)

Optionally, you may download, complete and return to us this pdfPDF version of the questionnaire.
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Page 1 of 7

  1. Patient Name:*
    Please enter the patient's name
  2. Email:*
    Invalid Input
  3. Below is a list of statements that others with your illness have found to be important. By checking one (1) number per line, please indicate how true each statement has been for you during the past 7 days.
  4. PHYSICAL WELL BEING

    0=Not at all  1=A little bit  2=Some what  3=Quite a bit  4=Very Much

  5. I have a lack of energy*
    Please make a selection
  6. I have nausea*
    Please make a selection
  7. Because of my physical condition, I have trouble meeting the needs of my family*
    Please make a selection
  8. I have pain*
    Please make a selection
  9. I am bothered by side effects of treatment*
    Please make a selection
  10. I feel ill*
    Please make a selection
  11. I am forced to spend time in bed*
    Please make a selection
  12.  
  1. EMOTIONAL WELL BEING

    0=Not at all  1=A little bit  2=Some what  3=Quite a bit  4=Very Much

  2. I feel sad*
    Please make a selection
  3. I am dissatisfied with how I am coping with my illness*
    Please make a selection
  4. I am losing hope in the fight against my illness*
    Please make a selection
  5. I feel nervous*
    Please make a selection
  6. I worry about dying*
    Please make a selection
  7. I worry that my condition will get worse*
    Please make a selection
  8.  
  1. SOCIAL/FAMILY WELL BEING

    0=Not at all  1=A little bit  2=Some what  3=Quite a bit  4=Very Much

  2. I feel close to my friends*
    Please make a selection
  3. I get emotional support from my family*
    Please make a selection
  4. I get support from my friends*
    Please make a selection
  5. My family has accepted my illness*
    Please make a selection
  6. I am satisfied with family communication about my illness*
    Please make a selection
  7. I feel close to my partner (or the person who is my main support)*
    Please make a selection
  8. Regardless of your current sexual activity, please tell us if you are satisfied with your sex life.

    If you prefer not to answer it, please check "Rather not answer" and go to the next section.*
    Please make a selection
  9. I am satisfied with my sex life*
    Please make a selection
  10.  
  1. FUNCTIONAL WELL BEING

  2. I am able to work (include work at home)*
    Please make a selection
  3. My work (include work at home) is fulfilling*
    Please make a selection
  4. I am able to enjoy life*
    Please make a selection
  5. I have accepted my illness*
    Please make a selection
  6. I am sleeping well*
    Please make a selection
  7. I am enjoying the things I usually do for fun*
    Please make a selection
  8. I am content with the quality of my life right now*
    Please make a selection
  9.  
  1. QUALITY OF LIFE SCALE

  2. On a scale of 0 to 10, with 0 being such poor quality of life that it would not be worth continuing to live, and 10 being the best quality of life you have ever had, at what number would you rate the following?
  3. Quality of life the past day.*
    Please enter a number from 0 to 10
  4. Quality of life the past 7 days.*
    Please enter a number from 0 to 10
  5. Quality of life the past month.*
    Please enter a number from 0 to 10
  6.  
  1. PAIN SCALE

  2. On a scale of 0 to 10, 0 being no pain, and 10 being the worst pain you have ever had in your life, at what level is your pain at this moment? *
    Please enter a number between 0 and 10
  3. Using the same scale, what has been your average pain level in:
  4. The past 24 hours*
    Please enter a number between 0 and 10
  5. The past week*
    Please enter a number between 0 and 10
  6. The past month*
    Please enter a number between 0 and 10
  7. Would you say that your amount of pain medicine over the past month has: *
    Please make a selection
  8. What is your normal weight?*
    Please enter your normal weight here
    Please enter weight in kg or lbs.
  9. What is your current weight?*
    Please enter your current weight here
    Please enter weight in kg or lbs.
  10.  
  • Please list all medications you are currently taking below
  1. Medication
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  3. Condition Prescribed For
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  1. Please enter the characters in the field below.*
    Please enter the characters in the field above