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Quality of Life Inventory
来源： 作者： 点击:次 时间：2009-04-19
Quality of Life Inventory
DATE ___/___/___
MM DDYY
Below is a list of statements that other people with your illness have said are important. By circling one number per line, please indicate how true each statement has been for you during the past 7 days.
During the past 7 days:
PHYSICAL WELL-BEING
0 not at a little all
1 some-bit
2 quite what
3 very a bit
4 much
1. I have a lack of energy
2. I have nausea
3. Because of my physical condition, I have trouble meeting the needs of my family
4. I have pain
5. I am bothered by side effects of treatment
6. I feel sick
7. I am forced to spend time in bed
8. Looking at the above 7 questions, how would you say your PHYSICAL WELL- BEING affects your quality of life? (Circle one number)
0 1 2 3 4 5 6 7 8 9 10
Not at all Very much so
During the past 7 days:
SOCIAL/FAMILY WELL-BEING
0 not at a little all
1 some-bit
2 quite what
3 very a bit
4 much
9. I feel distant from my friends
10. I get emotional support from my family
11. I get support from my friends and neighbors
12. My family has accepted my illness
13. Family communication about my illness is poor
14. I feel close to my partner (or the person who is my main support)
15. Looking at the above 6 questions, how would you say your SOCIAL/FAMILY WELL-BEING affects your quality of life? (Circle one number)
0 1 2 3 4 5 6 7 8 9 10
Not at all Very much so
During the past 7 days:
RELATIONSHIP WITH DOCTOR
0 not at a little all
1 some-bit
2 quite what
3 very a bit
4 much
16. I have confidence in my doctor(s)
17. My doctor is available to answer my questions
18. Looking at the above 6 questions, how would you say your RELATIONSHIP WITH THE DOCTOR affects your quality of life? (Circle one number)
0 1 2 3 4 5 6 7 8 9 10
Not at all Very much so
During the past 7 days:
EMOTIONAL WELL-BEING
0 not at a little all
1 some-bit
2 quite what
3 very a bit
4 much
19. I feel sad
20. I am proud of how I’m coping with my illness
21. I am losing hope in the fight against my illness
22. I feel nervous
23. I worry about dying
24. I worry that my condition will get worse
25. Looking at the above 6 questions, how would you say your EMOTIONAL WELL-BEING affects your quality of life? (Circle one number)
0 1 2 3 4 5 6 7 8 9 10
Not at all Very much so
During the past 7 days:
FUNCTIONAL WELL-BEING
0 not at a little all
1 some-bit
2 quite what
3 very a bit
4 much
26. I am able to work (include work in home)
27. My work (include work in home) is fulfilling
28. I am able to enjoy life
29. I have accepted my illness
30. I am sleeping well
31. I am enjoying the things I usually do for fun
32. I am content with the quality of my life right now
33. Looking at the above 7 questions, how would you say your FUNCTIONAL WELL-BEING affects your quality of life? (Circle one number)
0 1 2 3 4 5 6 7 8 9 10
Not at all Very much so
During the past 7 days:
ADDITIONAL CONCERNS
0 not at a little all
1 some-bit
2 quite what