Optional Health Assessment Modules Form Page 9
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27OPTIONAL MODULE 5:
UR Number:
QUALITY OF LIFE
Surname:
Given name:
(World Health Organisation Quality
Date of birth:
of Life-BREF)
(Please fill in if no label available)
PURPOSE OF MODULE
PURPOSE OF MODULE
INTRODUCTION FOR CLIENT
INTRODUCTION FOR CLIENT
To assess the client’s perceived physical health.
To assess the client’s perceived quality of life.
“Now I am going to ask you your physical health and conduct a basic
“Now I am going to ask you about how you feel about your quality of life,
physical health check.”
health, or other areas of your life. Please answer all the questions. If you
WHO CAN ADMINISTER THIS MODULE?
WHO CAN ADMINISTER THIS MODULE?
are unsure about which response to give to a question, please choose the
INSTRUCTIONS
Only complete this module if you are a medical doctor or a nurse.
This module can be self-administered by the client if they have the ability
one that appears most appropriate. This can often be your first response.”
1. Introduce module to client.
or desire to do so, or can be administered by the clinician.
2. As questions and perform relevant tests.
INSTRUCTIONS
3. Formulate responses and note actions to be taken.
1. Introduce module to client.
2. Ask all questions and circle responses on the 5-point scale provided.
3. Score module using the scoring guide.
4. Re-administer to monitor progress.
VERY POOR
POOR
NEITHER POOR
GOOD
VERY GOOD
NOR GOOD
1. How would you rate the quality of
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your life?
VERY
DISSATISFIED
NEITHER
SATISFIED
VERY
DISSATISFIED
SATISFIED NOR
SATISFIED
DISSATISFIED
2. How satisfied are you with your
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health?
The following questions ask about how much you have experienced certain things in the last two weeks.
NOT AT ALL
A LITTLE
A MODERATE
VERY MUCH
AN EXTREME
AMOUNT
AMOUNT
3. To what extent do you feel that
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physical pain prevents you from
doing what you need to do?
4. How much do you need any
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medical treatment to function in
your daily life?
5. How much do you enjoy life?
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FOR STAFF ONLY
Clinician name:
Position:
Signature:
Date:
8
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