Quality of Life Assessment

(use the back of this page if you don't have enough room to answer any of the questions below)

1.    On a scale of 1 to 10, where 1 is "THE PITS" or "TERRIBLE" and 10 is "GREAT",
how would you rate your life right now (circle the best answer)?

         1            2            3            4            5            6            7            8            9            10

2.    What was your main ROLE or OCCUPATION during your life?

3.    What is your main HEALTH PROBLEM? What do you think is CAUSING your main health problem?

4.    What is the one thing you do that you ENJOY THE MOST?

5.    What is the most MEMORABLE EXPERIENCE of your life?

6.    What are you most PROUD of?

7.    What is the main thing KEEPING YOU FROM ENJOYING life to its fullest?

8.    What are your main FEARS and WORRIES?

9.    What EMBARRASSES you the most?

10.    What REGRETS do you have?

11.    What GOALS do you have at this point in your life?

12.    Is there anything else that BOTHERS you or that you think we should know about in order to best help you?

13.    Do you have any specific QUESTIONS you would like answered at the Health Fair?

Copyright 2004. Robert S. Stall, MD / Stall Geriatrics. All Rights Reserved.