Quality of life assessment

Quality of life questionnaire

Basic info

Events – things that have happened to you since your last visit (existing patient) or in the past year (new patient)

Issues – how you felt most days in the past week

Wishes – what are ONE or TWO main things that would make your life better (besides good health and money)?


Recent Significant Events References

Called your PCP office – check out A Doctor’s Guide to a Good Appointment
Called a specialist office – check out Many Patients Don’t Pursue Referrals
Car accident – check out Older Drivers
Death of a spouse – check out Mourning the Death of a Spouse
Death of a friend – check out Coping with the Death of a Friend

Significant or Intolerable Issues References

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 disability or being a burden – check out 5 Signs That Your Biggest Fear is ‘Being a Burden’
Indigestion/nausea – check out Indigestion
Low energy – check out Fatigue in Older Adults
Low mood – check out Depression and Older Adults
Managing your health problems – check out Health Screening
Managing your medications – check out Taking Medicines Safely as You Age and Saving Money on Medicines
Overall health/quality of life – check out Quality of life and 10 Things You Can Do to Improve Your Life Right Now
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
Shortness of breath – check out COPD
Unintentional weight loss – check out Unintentional Weight Loss in Older Adults
Urine leakage/incontinence – check out Urinary Incontinence in Older Adults
If anything develops, make sure you let your PCP know!

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