Quality of life questionnaire Complete, print, and bring to any visit you have with a health professional. Quality of life questionnaire Basic info Pt ID (assigned by your doctor's practice) Practice/Physician/Group Ethnicity White Black Latino Asian Native American Non-native American Mixed OtherOther Date form completed Visit type Existing patient visit New patient visit OtherOther Patient date of birth Patient sex Female Male OtherOther Completed by Self Spouse/partner Son Daughter Grandchild Friend Aide Nurse PT/OT OtherOther Email address you would like a copy of this form sent to Events - things that have happened to you since your last visit (existing patient) or in the past year (new patient) Called your PCP office No Yes Called a specialist office No Yes Car accident No Yes Death of a spouse No Yes Death of other close relative No Yes Death of a friend No Yes Death of a pet No Yes ER visit No Yes Fall No Yes Hospital stay No Yes Moved No Yes New device (cane, walker, wheelchair) No Yes New non-prescription medication or supplement No Yes Events - things that have happened to you since your last visit (existing patient) or in the past year (cont.) New prescription medication No Yes Outpatient rehab No Yes PCP visit No Yes Rehab stay No Yes Specialist visit No Yes Stopped driving No Yes Stopped a medication on your own No Yes Surgery - elective No Yes Surgery - emergency No Yes Test done (blood, xray) No Yes Urgent care visit No Yes Issues - how you felt most days in the past week Anxiety/stress Not a problem Somewhat a problem Significant problem Intolerable Caring for someone else Not a problem Somewhat a problem Significant problem Intolerable Chest pain or pressure Not a problem Somewhat a problem Significant problem Intolerable Constipation Not a problem Somewhat a problem Significant problem Intolerable Difficulty walking Not a problem Somewhat a problem Significant problem Intolerable Dizziness Not a problem Somewhat a problem Significant problem Intolerable Fear of death Not a problem Somewhat a problem Significant problem Intolerable Fear of disability or being a burden Not a problem Somewhat a problem Significant problem Intolerable Fear of falling Not a problem Somewhat a problem Significant problem Intolerable Indigestion/nausea Not a problem Somewhat a problem Significant problem Intolerable Loneliness/boredom Not a problem Somewhat a problem Significant problem Intolerable Low energy Not a problem Somewhat a problem Significant problem Intolerable Low mood Not a problem Somewhat a problem Significant problem Intolerable Managing your health problems Not a problem Somewhat a problem Significant problem Intolerable Managing your medications Not a problem Somewhat a problem Significant problem Intolerable Memory loss Not a problem Somewhat a problem Significant problem Intolerable Overall health/quality of life Not a problem Somewhat a problem Significant problem Intolerable Pain Not a problem Somewhat a problem Significant problem Intolerable Poor appetite Not a problem Somewhat a problem Significant problem Intolerable Poor sleep Not a problem Somewhat a problem Significant problem Intolerable Urine leakage/incontinence Not a problem Somewhat a problem Significant problem Intolerable Sex life Not a problem Somewhat a problem Significant problem Intolerable Shortness of breath Not a problem Somewhat a problem Significant problem Intolerable Unintentional weight loss Not a problem Somewhat a problem Significant problem Intolerable Unsteadiness Not a problem Somewhat a problem Significant problem Intolerable Worries/regrets Not a problem Somewhat a problem Significant problem Intolerable Wishes - what are ONE or TWO main things that would make your life better? Wishes Scores Past events score (max 24) - how many significant things have happened to you recently Issues score (max 78) - how much things are bothering you Suggestions Events 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 other close relative - check out How to cope with death the first time you lose someone close, Bereavement, and Grief: Coping with the loss of your loved one. Death of a friend - check out Coping with the Death of a Friend. Death of a pet - check out 7 Self-Care Essentials While Grieving the Death of a Pet, Coping with the loss of a pet, and Why We Need to Take Pet Loss Seriously. ER visit - check out ER Trip May Point to Other Issues for Older Adults and Top 10 Reasons Seniors Go to the ER. Fall - check out Falls in the Elderly, Falls in the Elderly, What Causes Falls in the Elderly? How Can I Prevent a Fall?, Falls in the Elderly Statistics, and Deaths From Falls Surge for Elderly. Hospital stay - check out The Psychological Effect of a Hospital Stay on Seniors, After Hospitalization, Mental Trouble for Elderly Patients and For elderly patients, hospital stays often worsen disabilities. Moved - check out A Moving Concern: Transitional Trauma. New device - check out Geriatric Assistive Devices and Assistive Technology Helps People Age in Place. 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. Outpatient rehab - check out Understanding Physical Therapy for Seniors, Physical Therapy for Seniors, Physical Therapy a Boon for Seniors, and 4 Types of Physical Therapy for Seniors. PCP visit - check out Why Don’t Patients Follow Their Doctors’ Advice? and The Doctor’s Advice Most Ignored By Patients. Rehab stay - check out The transition from hospital to rehab or home | Best of Care, 13 Things to Know About Sub Acute Rehab, What is Subacute Nursing Home Care? and Getting the Right Care After a Hospital Discharge. Specialist visit - check out When Do You Need a Specialist Doctor?. Stopped driving - check out When Should Older Adults Stop Driving?. Stopped a medication on your own - check out 3 Reasons Why Seniors Aren’t Taking Medication as Prescribed and How to Help and The Top 6 Reasons Elderly People Don't Take Medication. Surgery - elective - check out Study: Frailty in seniors raises mortality risk related to elective surgery, Is Surgery Right for Your Older Loved One?, Avoiding Surgery in the Elderly, and Elderly Patients and Surgical Risk. Surgery - emergency - check out Emergency surgery in the elderly: challenges and solutions. Test done - check out Medical Tests in your 60s and Up and Top 10 Blood Tests for Older Adults: What to Know. Urgent care visit - check out Emergency! Yes? No. Urgent Care Centers are on the Rise, Filling in the Care Gap for Elders and Emergency Rooms Are No Place for the Elderly. 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 death - check out 6 Positive Ways To Overcome Your Fear Of Death. Fear of disability or being a burden - check out Moving Past Your Fear of Being a Burden. Fear of falling - check out Prevent Falls and Fractures, 5 Ways to Ease Your Fear of Falling, and Conquering Fear of Falling. Indigestion/nausea - check out Indigestion. Loneliness/boredom - check out Easing Old People's Loneliness Can Help Keep Them Healthy. 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. Memory loss - check out Do Memory Problems Always Mean Alzheimer's Disease? and Basics of Alzheimer's Disease and Dementia. 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 appetite - check out Healthy Eating and Taking Care of Your Teeth and Mouth. 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. Unsteadiness - check out Gait and Balance Disorders in Older Adults. Urine leakage/incontinence - check out Urinary Incontinence in Older Adults. Worries/regrets - check out and The 25 Biggest Regrets In Life. What Are Yours? and The Most Surprising Regret Of The Very Old — And How You Can Avoid It. If you are human, leave this field blank.
