Quality of life questionnaire

Complete, print, and bring to any visit you have with a health professional.

Quality of life questionnaire

Basic info

Events - things that have happened to you since your last visit (existing patient) or in the past year (new patient)

Events - things that have happened to you since your last visit (existing patient) or in the past year (cont.)

Issues - how you felt most days in the past week

Wishes - what are ONE or TWO main things that would make your life better?




Called your PCP office - check out Doctor Visit Guide.
Called a specialist office - check out Many Patients Don't Pursue Referrals.
Car accident - check out Senior Driving and Older Drivers.
Death of a spouse - check out Mourning the Death of a Spouse.
Death of a friend - check out Coping with the Death of a Friend.
New non-prescription medication or supplement - check out Dietary Supplements.
New prescription medication - check out Medications and Older Adults and Drug-Related Problems in Older Adults.
Specialist visit - check out When Do You Need a Specialist Doctor?.
Stopped driving - check out When Should Older Adults Stop Driving?.

Significant or Intolerable Issues

Anxiety/stress - check out Anxiety & Older Adults, Elder Abuse, and Crimes Against Seniors.
Caring for someone else - check out 7 Tips to Avoid Caregiver Burnout.
Chest pain or pressure - check out Heart Health.
Constipation - check out Concerned About Constipation?.
Difficulty walking - check out Gait and Balance Disorders in Older Adults.
Dizziness - check out Dizziness and Vertigo.
Fear of disability or being a burden - check out Moving Past Your Fear of Being a Burden.
Indigestion/nausea - check out Indigestion.
Low energy - check out Fatigue in Older Adults.
Low mood - check out Depression In Older Adults.
Managing your health problems - check out Health Screening.
Managing your medications - check out Safe Use of Medicines and Saving Money on Medicines.
Overall health/quality of life - check out Quality of life and 10 Things You Can Do Today to Improve Your Life.
Pain - check out Pain: You Can Get Help.
Poor sleep - check out A Good Night's Sleep and Aging Changes In Sleep.
Sex life - check out Sexuality in Later Life.
Shortness of breath - check out Breathing Problems and COPD.
Unintentional weight loss - check out Unintentional Weight Loss in Older Adults.
Urine leakage/incontinence - check out Urinary Incontinence in Older Adults.

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