Quality of life scale

Client Name

 

Assessment Date

 

______________________________
_______________

How do your rate your overall quality of life? What could make it better?

On a scale of 1 to 10, where 1 is “terrible” and 10 is “great!”, how would you rate your life right now (circle one)?

1 2 3 4 5 6 7 8 9 10

What is one thing you wish or think could be better to make your quality of life increase?

1.

What is another thing you wish or think could be better to make your quality of life increase?

2.

And a third thing you wish or think could be better to make your quality of life increase?

3.

Comments:

Discuss with your primary care doctor ways you can improve your overall quality of life to one more than what you rated it.

For example, if you said “5”, try to aim for a “6”. Even if you said your were a “10”, try to work toward an “11”.
Or if you were “‐1”, try to figure out how to get to a “0”.

Assessed By

 

Signature

 

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References

Copyright © Stall Geriatrics LLC – What Should You Expect At Your Age? A Lot!
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