Download:
pdf |
pdfID# __________________________
Date:_________________________
PedsQL
™
Pediatric Quality of Life
Inventory
Version 4.0 Short Form (SF15)
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.
PedsQL 4.0 - (13-18)-SF15
03/00
Not to be reproduced without permission
Copyright © 1998 JW Varni, Ph.D.
All rights reserved
PedsQL 2
In the past ONE month, how much of a problem has this been for you …
Never
Almost
Never
Sometimes
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 do chores around the house
0
1
2
3
4
Never
Almost
Never
Sometimes
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 worry about what will happen to me
0
1
2
3
4
Never
Almost
Never
Sometimes
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
Never
Almost
Never
Sometimes
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
ABOUT MY HEALTH AND ACTIVITIES (problems with…)
ABOUT MY FEELINGS (problems with…)
HOW I GET ALONG WITH OTHERS (problems with…)
ABOUT SCHOOL (problems with…)
PedsQL 4.0 - (13-18)-SF15
03/00
Not to be reproduced without permission
Copyright © 1998 JW Varni, Ph.D.
All rights reserved
ID#__________________________
Date:________________________
PedsQL
™
Pediatric Quality of Life
Inventory
Version 4.0 Short Form (SF15)
PARENT REPORT for TEENS (ages 13-18)
DIRECTIONS
On the following page is a list of things that might be a problem for your teen.
Please tell us how much of a problem each one has been for your teen
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.
PedsQL 4.0 - Parent (13-18)-SF15
03/00
Not to be reproduced without permission
Copyright © 1998 JW Varni, Ph.D.
All rights reserved
PedsQL 2
In the past ONE month, how much of a problem has your teen had with …
Never
Almost
Never
Sometimes
Often
Almost
Always
1. Walking more than one block
0
1
2
3
4
2. Running
0
1
2
3
4
3. Participating in sports activity or exercise
0
1
2
3
4
4. Lifting something heavy
0
1
2
3
4
5. Doing chores around the house
0
1
2
3
4
Never
Almost
Never
Sometimes
Often
Almost
Always
1. Feeling afraid or scared
0
1
2
3
4
2. Feeling sad or blue
0
1
2
3
4
3. Feeling angry
0
1
2
3
4
4. Worrying about what will happen to him or her
0
1
2
3
4
Never
Almost
Never
Sometimes
Often
Almost
Always
1. Getting along with other teens
0
1
2
3
4
2. Other teens not wanting to be his or her friend
0
1
2
3
4
3. Getting teased by other teens
0
1
2
3
4
Never
Almost
Never
Sometimes
Often
Almost
Always
1. Paying attention in class
0
1
2
3
4
2. Forgetting things
0
1
2
3
4
3. Keeping up with schoolwork
0
1
2
3
4
PHYSICAL FUNCTIONING (problems with…)
EMOTIONAL FUNCTIONING (problems with…)
SOCIAL FUNCTIONING (problems with…)
SCHOOL FUNCTIONING (problems with…)
PedsQL 4.0 - Parent (13-18)-SF15
03/00
Not to be reproduced without permission
Copyright © 1998 JW Varni, Ph.D.
All rights reserved
ID# __________________________
Date:_________________________
PedsQL
™
Pediatric Quality of Life
Inventory
Version 4.0 Short Form (SF15)
CHILD REPORT (ages 8-12)
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.
PedsQL 4.0 - (8-12)-SF15
03/00
Not to be reproduced without permission
Copyright © 1998 JW Varni, Ph.D.
All rights reserved
PedsQL 2
In the past ONE month, how much of a problem has this been for you …
Never
Almost
Never
Sometimes
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 do chores around the house
0
1
2
3
4
Never
Almost
Never
Sometimes
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 worry about what will happen to me
0
1
2
3
4
Never
Almost
Never
Sometimes
Often
Almost
Always
1. I have trouble getting along with other kids
0
1
2
3
4
2. Other kids do not want to be my friend
0
1
2
3
4
3. Other kids tease me
0
1
2
3
4
Never
Almost
Never
Sometimes
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
ABOUT MY HEALTH AND ACTIVITIES (problems with…)
ABOUT MY FEELINGS (problems with…)
HOW I GET ALONG WITH OTHERS (problems with…)
ABOUT SCHOOL (problems with…)
PedsQL 4.0 - (8-12)-SF15
03/00
Not to be reproduced without permission
Copyright © 1998 JW Varni, Ph.D.
All rights reserved
ID# __________________________
Date:_________________________
PedsQL
™
Pediatric Quality of Life
Inventory
Version 4.0 Short Form (SF15)
PARENT REPORT for CHILDREN (ages 8-12)
DIRECTIONS
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 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.
PedsQL 4.0 - Parent (8-12)-SF15
03/00
Not to be reproduced without permission
Copyright © 1998 JW Varni, Ph.D.
All rights reserved
PedsQL 2
In the past ONE month, how much of a problem has your child had with …
Never
Almost
Never
Sometimes
Often
Almost
Always
1. Walking more than one block
0
1
2
3
4
2. R unning
0
1
2
3
4
3. P articipating in sports activity or exercise
0
1
2
3
4
4. Lifting something heavy
0
1
2
3
4
5. D oing chores around the house
0
1
2
3
4
Never
Almost
Never
Sometimes
Often
Almost
Always
1. Feeling afraid or scared
0
1
2
3
4
2. Feeling sad or blue
0
1
2
3
4
3. Feeling angry
0
1
2
3
4
4. Worrying about what will happen to him or her
0
1
2
3
4
Never
Almost
Never
Sometimes
Often
Almost
Always
1. Getting along with other children
0
1
2
3
4
2. Other kids not wanting to be his or her friend
0
1
2
3
4
3. Getting teased by other children
0
1
2
3
4
Never
Almost
Never
Sometimes
Often
Almost
Always
1. Paying attention in class
0
1
2
3
4
2. Forgetting things
0
1
2
3
4
3. Keeping up with schoolwork
0
1
2
3
4
PHYSICAL FUNCTIONING (problems with…)
EMOTIONAL FUNCTIONING (problems with…)
SOCIAL FUNCTIONING (problems with…)
SCHOOL FUNCTIONING (problems with…)
PedsQL 4.0 - Parent (8-12)-SF15
03/00
Not to be reproduced without permission
Copyright © 1998 JW Varni, PhD.
All rights reserved
ID# __________________________
Date:_________________________
™
PedsQL
Pediatric Quality of Life
Inventory
Version 4.0 Short Form (SF15)
YOUNG CHILD REPORT (ages 5-7)
Instructions for interviewer:
I am going to ask you some questions about things that might be a problem for some
children. I want to know how much of a problem any of these things might be for you.
Show the child the template and point to the responses as you read .
If it is not at all a problem for you, point to the smiling face
If it is sometimes a problem for you, point to the middle face
If it is a problem for you a lot, point to the frowning face
I will read each question. Point to the pictures to show me how much of a problem it is
for you. Let’s try a practice one first.
Is it hard for you to snap your fingers
Not at all
Sometimes
A lot
J
K
L
Ask the child to demonstrate snapping his or her fingers to determine whether or not the
question was answered correctly. Repeat the question if the child demonstrates a response that
is different from his or her action.
PedsQL 4.0 - (5-7)-SF15
Varni, Ph.D.
03/00
Not to be reproduced without permission
Copyright © 1998 JW
All rights reserved
PedsQL 2
Think about how you have been doing for the last few weeks. Please listen carefully to
each sentence and tell me how much of a problem this is for you.
After reading the item, gesture to the template. If the child hesitates or does not seem to understand
how to answer, read the response options while pointing at the faces.
PHYSICAL FUNCTIONING (problems with…)
1.
2.
3.
4.
5.
Is it hard for you to walk
Is it hard for you to run
Is it hard for you to play sports or exercise
Is it hard for you to pick up big things
Is it hard for you to do chores (like pick up your toys)
Not
at all
Sometimes
A lot
0
0
0
0
0
2
2
2
2
2
4
4
4
4
4
Remember, tell me how much of a problem this has been for you for the last few weeks.
EMOTIONAL FUNCTIONING (problems with…)
1.
2.
3.
4.
Do you feel scared
Do you feel sad
Do you feel mad
Do you worry about what will happen to you
SOCIAL FUNCTIONING (problems with…)
1. Is it hard for you to get along with other kids
2. Do other kids say they do not want to play with you
3. Do other kids tease you
SCHOOL FUNCTIONING (problems with…)
1. Is it hard for you to pay attention in school
2. Do you forget things
3. Is it hard to keep up with schoolwork
PedsQL 4.0 - (5-7)-SF15
03/00
Not to be reproduced without permission
Not
at all
Sometimes
A lot
0
0
0
0
2
2
2
2
4
4
4
4
Not
at all
Sometimes
A lot
0
0
0
2
2
2
4
4
4
Not
at all
Sometimes
A lot
0
0
0
2
2
2
4
4
4
Copyright © 1998 JW Varni, Ph.D.
All rights reserved
How much of a problem is this for you?
Not at all
J
PedsQL 4.0 - (5-7)-SF15
03/00
Sometimes
K
Not to be reproduced without permission
A lot
L
Copyright © 1998 JW Varni, PhD.
All rights reserved.
ID# __________________________
Date:_________________________
PedsQL
™
Pediatric Quality of Life
Inventory
Version 4.0 Short Form (SF15)
PARENT REPORT for YOUNG CHILDREN (ages 5-7)
DIRECTIONS
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 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.
PedsQL 4.0 - Parent (5-7)-SF15
03/00
Not to be reproduced without permission
Copyright © 1998 JW Varni, Ph.D.
All rights reserved
PedsQL 2
In the past ONE month, how much of a problem has your child had with …
Never
Almost
Never
Sometimes
Often
Almost
Always
1. Walking more than one block
0
1
2
3
4
2. R unning
0
1
2
3
4
3. P articipating in sports activity or exercise
0
1
2
3
4
4. Lifting something heavy
0
1
2
3
4
5. Doing chores, like picking up his or her toys
0
1
2
3
4
Never
Almost
Never
Sometimes
Often
Almost
Always
1. Feeling afraid or scared
0
1
2
3
4
2. Feeling sad or blue
0
1
2
3
4
3. Feeling angry
0
1
2
3
4
4. Worrying about what will happen to him or her
0
1
2
3
4
Never
Almost
Never
Sometimes
Often
Almost
Always
1. Getting along with other children
0
1
2
3
4
2. Other kids not wanting to be his or her friend
0
1
2
3
4
3. Getting teased by other children
0
1
2
3
4
Never
Almost
Never
Sometimes
Often
Almost
Always
1. Paying attention in class
0
1
2
3
4
2. Forgetting things
0
1
2
3
4
3. Keeping up with school activities
0
1
2
3
4
PHYSICAL FUNCTIONING (problems with…)
EMOTIONAL FUNCTIONING (problems with…)
SOCIAL FUNCTIONING (problems with…)
SCHOOL FUNCTIONING (problems with…)
PedsQL 4.0 - Parent (5-7)-SF15
Varni, Ph.D. 03/00
Not to be reproduced without permission
Copyright © 1998 JW
All rights reserved
ID# __________________________
Date:_________________________
PedsQL
™
Pediatric Quality of Life
Inventory
Version 4.0 Short Form (SF15)
PARENT REPORT for TODDLERS (ages 2-4)
DIRECTIONS
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 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.
PedsQL 4.0 - Parent (2-4)-SF15
03/00
Not to be reproduced without permission
Copyright © 1998 JW Varni, Ph.D.
All rights reserved
PedsQL 2
In the past ONE month, how much of a problem has your child had with …
Never
Almost
Never
Sometimes
Often
Almost
Always
1. Walking
0
1
2
3
4
2. Running
0
1
2
3
4
3. Participating in active play or exercise
0
1
2
3
4
4. Lifting something heavy
0
1
2
3
4
5. Helping to pick up his or her toys
0
1
2
3
4
Never
Almost
Never
Sometimes
Often
Almost
Always
1. Feeling afraid or scared
0
1
2
3
4
2. Feeling sad or blue
0
1
2
3
4
3. Feeling angry
0
1
2
3
4
4. Worrying
0
1
2
3
4
Never
Almost
Never
Sometimes
Often
Almost
Always
1. Playing with other children
0
1
2
3
4
2. Other kids not wanting to play with him or her
0
1
2
3
4
3. Getting teased by other children
0
1
2
3
4
Sometimes
Often
Never
Almost
Always
PHYSICAL FUNCTIONING (problems with…)
EMOTIONAL FUNCTIONING (problems with…)
SOCIAL FUNCTIONING (problems with…)
*Please complete this section if your child attends school or daycare
Never
Almost
SCHOOL FUNCTIONING (problems with…)
1. Doing the same school activities as peers
0
1
2
3
4
2. Missing school/daycare because of not feeling well
0
1
2
3
4
3. Missing school/daycare to go to the doctor or
hospital
0
1
2
3
4
PedsQL 4.0 – Parent (2-4)-SF15
03/00
Not to be reproduced without permission
Copyright © 1998 JW Varni, Ph.D.
All rights reserved
| File Type | application/pdf |
| File Title | PedsQL4-SF15_Core_A_usaor1_review copy.doc |
| Author | mpvirieux |
| File Modified | 2006-03-29 |
| File Created | 2006-03-28 |