Quality of Life Survey 2

1.

In July of this year Innervate (www.innervate.co.uk) is launching a conference for health professionals called LIFEPSYCHOL 2009. This event has the support of a number of organisations, all listed on the conference website, www.lifepsychol.com. As part of the event we will be talking about the term ‘quality of life’ and we would like to learn more about what ‘quality of life’ means to healthy people. To help generate that information we would be grateful if you could answer the following questions which shouldn’t take any longer than 10 minutes. If you do have a long term condition please do not complete this survey and go to http://www.surveymonkey.com/s.aspx?sm=pv5sMhBORF7oEXC_2faUwdlg_3d_3d

1. Please tell us whether you are male or female

Please tell us whether you are male or female Male

Female

2. What is your age at time of completing this questionnaire?

What is your age at time of completing this questionnaire? Less than 15 years of age

15 - 20 years of age

21 - 25 years of age

26 - 30 years of age

31 - 35 years of age

36 - 40 years of age

41 - 50 years of age

51 - 60 years of age

61 - 70 years of age

71 - 80 years of age

over 80 years of age

3. Do you work in the health service(Private or NHS)?

Do you work in the health service(Private or NHS)? Yes

4. Please rate how important the following are to you, where 1 is the least important and 11 is the most important. You cannot give the same rating to 2 or more items. e.g. It is not possible for you to score 11 for 'Feeling calm' and 'Being pain free' For the purposes of this survey we would like you to prioritise feeling or being:

	1	2	3	4	5	6	7	8	9	10	11
Calm	*Please rate how important the following are to you, where 1 is the least important and 11 is the most important. You cannot give the same rating to 2 or more items. e.g. It is not possible for you to score 11 for 'Feeling calm' and 'Being pain free' For the purposes of this survey we would like you to prioritise feeling or being: Calm 1	Calm 2	Calm 3	Calm 4	Calm 5	Calm 6	Calm 7	Calm 8	Calm 9	Calm 10	Calm 11
In a good mood	In a good mood 1	In a good mood 2	In a good mood 3	In a good mood 4	In a good mood 5	In a good mood 6	In a good mood 7	In a good mood 8	In a good mood 9	In a good mood 10	In a good mood 11
Pain free	Pain free 1	Pain free 2	Pain free 3	Pain free 4	Pain free 5	Pain free 6	Pain free 7	Pain free 8	Pain free 9	Pain free 10	Pain free 11
Able to have a good night’s sleep	Able to have a good night’s sleep 1	Able to have a good night’s sleep 2	Able to have a good night’s sleep 3	Able to have a good night’s sleep 4	Able to have a good night’s sleep 5	Able to have a good night’s sleep 6	Able to have a good night’s sleep 7	Able to have a good night’s sleep 8	Able to have a good night’s sleep 9	Able to have a good night’s sleep 10	Able to have a good night’s sleep 11
Able to have relationships (with friends and/or family)	Able to have relationships (with friends and/or family) 1	Able to have relationships (with friends and/or family) 2	Able to have relationships (with friends and/or family) 3	Able to have relationships (with friends and/or family) 4	Able to have relationships (with friends and/or family) 5	Able to have relationships (with friends and/or family) 6	Able to have relationships (with friends and/or family) 7	Able to have relationships (with friends and/or family) 8	Able to have relationships (with friends and/or family) 9	Able to have relationships (with friends and/or family) 10	Able to have relationships (with friends and/or family) 11
Financially secure	Financially secure 1	Financially secure 2	Financially secure 3	Financially secure 4	Financially secure 5	Financially secure 6	Financially secure 7	Financially secure 8	Financially secure 9	Financially secure 10	Financially secure 11
Able to function physically (e.g. get up and walk around, move arms/legs easily, go to the toilet with relative ease)	Able to function physically (e.g. get up and walk around, move arms/legs easily, go to the toilet with relative ease) 1	Able to function physically (e.g. get up and walk around, move arms/legs easily, go to the toilet with relative ease) 2	Able to function physically (e.g. get up and walk around, move arms/legs easily, go to the toilet with relative ease) 3	Able to function physically (e.g. get up and walk around, move arms/legs easily, go to the toilet with relative ease) 4	Able to function physically (e.g. get up and walk around, move arms/legs easily, go to the toilet with relative ease) 5	Able to function physically (e.g. get up and walk around, move arms/legs easily, go to the toilet with relative ease) 6	Able to function physically (e.g. get up and walk around, move arms/legs easily, go to the toilet with relative ease) 7	Able to function physically (e.g. get up and walk around, move arms/legs easily, go to the toilet with relative ease) 8	Able to function physically (e.g. get up and walk around, move arms/legs easily, go to the toilet with relative ease) 9	Able to function physically (e.g. get up and walk around, move arms/legs easily, go to the toilet with relative ease) 10	Able to function physically (e.g. get up and walk around, move arms/legs easily, go to the toilet with relative ease) 11
Independent (not reliant on others)	Independent (not reliant on others) 1	Independent (not reliant on others) 2	Independent (not reliant on others) 3	Independent (not reliant on others) 4	Independent (not reliant on others) 5	Independent (not reliant on others) 6	Independent (not reliant on others) 7	Independent (not reliant on others) 8	Independent (not reliant on others) 9	Independent (not reliant on others) 10	Independent (not reliant on others) 11
Able to complete domestic tasks	Able to complete domestic tasks 1	Able to complete domestic tasks 2	Able to complete domestic tasks 3	Able to complete domestic tasks 4	Able to complete domestic tasks 5	Able to complete domestic tasks 6	Able to complete domestic tasks 7	Able to complete domestic tasks 8	Able to complete domestic tasks 9	Able to complete domestic tasks 10	Able to complete domestic tasks 11
Able to have a social life/hobbies	Able to have a social life/hobbies 1	Able to have a social life/hobbies 2	Able to have a social life/hobbies 3	Able to have a social life/hobbies 4	Able to have a social life/hobbies 5	Able to have a social life/hobbies 6	Able to have a social life/hobbies 7	Able to have a social life/hobbies 8	Able to have a social life/hobbies 9	Able to have a social life/hobbies 10	Able to have a social life/hobbies 11
Able to have a working life	Able to have a working life 1	Able to have a working life 2	Able to have a working life 3	Able to have a working life 4	Able to have a working life 5	Able to have a working life 6	Able to have a working life 7	Able to have a working life 8	Able to have a working life 9	Able to have a working life 10	Able to have a working life 11

5. Please indicate to what extent you believe the following would or does negatively affect your quality of life

	No affect	Mild affect	Moderate affect	Severe affect
Feeling angry and/or frustrated	*Please indicate to what extent you believe the following would or does negatively affect your quality of life Feeling angry and/or frustrated No affect	Feeling angry and/or frustrated Mild affect	Feeling angry and/or frustrated Moderate affect	Feeling angry and/or frustrated Severe affect
Feeling anxious and/or depressed	Feeling anxious and/or depressed No affect	Feeling anxious and/or depressed Mild affect	Feeling anxious and/or depressed Moderate affect	Feeling anxious and/or depressed Severe affect
Suffering from fatigue/low energy levels	Suffering from fatigue/low energy levels No affect	Suffering from fatigue/low energy levels Mild affect	Suffering from fatigue/low energy levels Moderate affect	Suffering from fatigue/low energy levels Severe affect
Lack of sleep	Lack of sleep No affect	Lack of sleep Mild affect	Lack of sleep Moderate affect	Lack of sleep Severe affect
Pain	Pain No affect	Pain Mild affect	Pain Moderate affect	Pain Severe affect
Lack of mobility and/or physical function	Lack of mobility and/or physical function No affect	Lack of mobility and/or physical function Mild affect	Lack of mobility and/or physical function Moderate affect	Lack of mobility and/or physical function Severe affect
Deterioration in financial situation	Deterioration in financial situation No affect	Deterioration in financial situation Mild affect	Deterioration in financial situation Moderate affect	Deterioration in financial situation Severe affect
Deterioration in independence	Deterioration in independence No affect	Deterioration in independence Mild affect	Deterioration in independence Moderate affect	Deterioration in independence Severe affect
Inability to complete domestic tasks	Inability to complete domestic tasks No affect	Inability to complete domestic tasks Mild affect	Inability to complete domestic tasks Moderate affect	Inability to complete domestic tasks Severe affect
Deterioration in social life/ carrying out hobbies	Deterioration in social life/ carrying out hobbies No affect	Deterioration in social life/ carrying out hobbies Mild affect	Deterioration in social life/ carrying out hobbies Moderate affect	Deterioration in social life/ carrying out hobbies Severe affect
Deterioration in working life	Deterioration in working life No affect	Deterioration in working life Mild affect	Deterioration in working life Moderate affect	Deterioration in working life Severe affect
Deterioration in relationships	Deterioration in relationships No affect	Deterioration in relationships Mild affect	Deterioration in relationships Moderate affect	Deterioration in relationships Severe affect

6. In no more than 30 words please describe what ‘quality of life’ means to you.

In no more than 30 words please describe what ‘quality of life’ means to you.

7. How would you rate your current quality of life?

How would you rate your current quality of life? Terrible

Poor

Good

Very Good

Exeptional

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