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The following questions ask how you feel about your quality of life, health, or other areas of
your life. I will read out each question to you, along with the response options. Please choose
the answer that appears most appropriate. If you are unsure about which response to give
to a question, the first response you think of is often the best one.
Please keep in mind your standards, hopes, pleasures and concerns. We ask that you think
about your life in the last four weeks.
Neither poor
Very poor Poor Good Very good
nor good
1. How would you rate your
1 2 3 4 5
quality of life?
Neither
Very Very
Dissatisfied satisfied nor Satisfied
dissatisfied satisfied
dissatisfied
2. How satisfied are you with your
1 2 3 4 5
health?
The following questions ask about how much you have experienced certain things in the last
four weeks.
A moderate An extreme
Not at all A little Very much
amount amount
3. To what extent do you feel that
physical pain prevents you
5 4 3 2 1
from
doing what you need to do?
4. How much do you need any
medical treatment to function 5 4 3 2 1
in your daily life?
5. How much do you enjoy life? 1 2 3 4 5
6. To what extent do you feel your
1 2 3 4 5
life to be meaningful?
A moderate
Not at all A little Very much Extremely
amount
7. How well are you able to
1 2 3 4 5
concentrate?
8. How safe do you feel in your
1 2 3 4 5
daily life?
9. How healthy is your physical
1 2 3 4 5
environment?
The following questions ask about how completely you experience or were able to do certain
things in the last four weeks.
Neither poor
Very poor Poor Good Very good
nor good
15. How well are you able to get
1 2 3 4 5
around?
Neither
Very Very
Dissatisfied satisfied nor Satisfied
dissatisfied satisfied
dissatisfied
16. How satisfied are you with your
1 2 3 4 5
sleep?
17. How satisfied are you with
your ability to perform your 1 2 3 4 5
daily living activities?
18. How satisfied are you with
1 2 3 4 5
your capacity for work?
19. How satisfied are you with
1 2 3 4 5
yourself?
20. How satisfied are you with your
1 2 3 4 5
personal relationships?
21. How satisfied are you with
1 2 3 4 5
your sex life?
22. How satisfied are you with the
support you get from your 1 2 3 4 5
friends?
23. How satisfied are you with the
1 2 3 4 5
conditions of your living place?
24. How satisfied are you with your
1 2 3 4 5
access to health services?
25. How satisfied are you with
1 2 3 4 5
your transport?
The following question refers to how often you have felt or experienced certain things in the
last four weeks.
Transformed scores*
Equations for computing domain scores Raw score
4-20 0-100
27. Domain 1 (6-Q3) + (6-Q4) + Q10 + Q15 + Q16 + Q17 + Q18
a. = b: c:
+ + + + + +
28. Domain 2 Q5 + Q6 + Q7 + Q11 + Q19 + (6-Q26)
a. = b: c:
+++ + +
29. Domain 3 Q20 + Q21 + Q22
a. = b: c:
+ +
30. Domain 4 Q8 + Q9 + Q12 + Q13 + Q14 + Q23 + Q24 + Q25
a. = b: c:
++ + + + + +