Form 006_Sickle Cell_Pe 006_Sickle Cell_Pe 006_Sickle Cell_PedsQL_Child_teens

PedsQL 3

ID# __________________________

Date:_________________________

PedsQL ^™

Pediatric Quality of Life

Inventory

Version 4.0

TEEN REPORT (ages 13-18)

DIRECTIONS

On the following page is a list of things that might be a problem for you.

Please tell us how much of a problem each one has been for you

during the past ONE 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.

In the past ONE month, how much of a problem has this been for you …

About My Health and Activities (problems with…)	Never	Almost Never	Some-times	Often	Almost Always
1. It is hard for me to walk more than one block	0	1	2	3	4
2. It is hard for me to run	0	1	2	3	4
3. It is hard for me to do sports activity or exercise	0	1	2	3	4
4. It is hard for me to lift something heavy	0	1	2	3	4
5. It is hard for me to take a bath or shower by myself	0	1	2	3	4
6. It is hard for me to do chores around the house	0	1	2	3	4
7. I hurt or ache	0	1	2	3	4
8. I have low energy	0	1	2	3	4

About My Feelings (problems with…)	Never	Almost Never	Some-times	Often	Almost Always
1. I feel afraid or scared	0	1	2	3	4
2. I feel sad or blue	0	1	2	3	4
3. I feel angry	0	1	2	3	4
4. I have trouble sleeping	0	1	2	3	4
5. I worry about what will happen to me	0	1	2	3	4

How I Get Along with Others (problems with…)	Never	Almost Never	Some-times	Often	Almost Always
1. I have trouble getting along with other teens	0	1	2	3	4
2. Other teens do not want to be my friend	0	1	2	3	4
3. Other teens tease me	0	1	2	3	4
4. I cannot do things that other teens my age can do	0	1	2	3	4
5. It is hard to keep up with my peers	0	1	2	3	4

About School (problems with…)	Never	Almost Never	Some-times	Often	Almost Always
1. It is hard to pay attention in class	0	1	2	3	4
2. I forget things	0	1	2	3	4
3. I have trouble keeping up with my schoolwork	0	1	2	3	4
4. I miss school because of not feeling well	0	1	2	3	4
5. I miss school to go to the doctor or hospital	0	1	2	3	4

PedsQL 4.0 - (13-18) Not to be reproduced without permission Copyright © 1998 JW Varni, Ph.D. All rights reserved

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PedsQL-4.0-Core – US/English

PedsQL-4.0-Core-A_AU4.0_eng-US.ori.doc