1 Instrumen QOL General Usia 2 Sampai 4 Tahun
1 Instrumen QOL General Usia 2 Sampai 4 Tahun
ID#
Date:
TM
Pe d s Q L
Paediatric Quality of Life
Inventory
Version 4.0 – UK English
PARENT REPORT for TODDLERS (ages 2-4)
DIRECTION
S
On the following page is a list of things that might be a problem for your child.
Please tell us how much of a problem each one has been for your child during
the PAST MONTH by circling:
0 if it is never a problem
1 if it is almost never a problem
2 if it is sometimes a problem
3 if it is often a problem
4 if it is almost always a problem
There are no right or wrong answers.
If you do not understand a question, please ask for help.
PedsQL 4.0 – Parent (2-4) f:\institut\cultadap\project\pg2161\etude2161\final_versions\format_jimvarni\uk\ Copyright © 1998 JW Varni, Ph.D. All rights reserved
pedsql4-core-pt-uk.doc APRIL 2004 Not to be reproduced without permission
PedsQL 2
In the PAST MONTH, how much of a problem has your child had with …
PHYSICAL FUNCTIONING (problems with…) Never Almost Some- Often Almost
Never times Always
1. Walking 0 1 2 3 4
2. Running 0 1 2 3 4
3. Participating in active play and exercise 0 1 2 3 4
4. Lifting heavy things 0 1 2 3 4
5. Bathing 0 1 2 3 4
6. Helping to pick up his or her toys 0 1 2 3 4
7. Having aches or pains 0 1 2 3 4
8. Feeling tired 0 1 2 3 4
EMOTIONAL FUNCTIONING (problems with…) Never Almost Some- Often Almost
Never times Always
1. Feeling afraid or scared 0 1 2 3 4
2. Feeling sad 0 1 2 3 4
3. Feeling angry 0 1 2 3 4
4. Having trouble sleeping 0 1 2 3 4
5. Worrying 0 1 2 3 4
SOCIAL FUNCTIONING (problems with…) Never Almost Some- Often Almost
Never times Always
1. Playing with other children 0 1 2 3 4
2. Other children not wanting to play with him or her 0 1 2 3 4
3. Getting teased by other children 0 1 2 3 4
4. Not able to do things that other children his or her age can 0 1 2 3 4
do
5. Keeping up when playing with other children 0 1 2 3 4
*Please complete this section if your child attends nursery or day care
NURSERY/DAY CARE FUNCTIONING (problems Never Almost Some- Often Almost
Never times Always
with…)
1. Doing the same nursery/day care activities as peers 0 1 2 3 4
2. Missing nursery/day care because of not feeling well 0 1 2 3 4
3. Missing nursery/day care to go to the doctor or hospital 0 1 2 3 4
PedsQL 4.0 – Parent (2-4) f:\institut\cultadap\project\pg2161\etude2161\final_versions\format_jimvarni\uk\ Copyright © 1998 JW Varni, Ph.D. All rights reserved
pedsql4-core-pt-uk.doc APRIL 2004 Not to be reproduced without permission