Neurological Quality of Life Questionnaire
Please complete this questionnaire to help assess how neurological symptoms affect your daily life and well-being.
Full Name
*
First Name
Last Name
Age
*
Gender
*
Male
Female
Other / Prefer not to say
In the past 7 days, how much have the following symptoms affected your daily life?
*
Rows
Not at all
A little
Moderately
Quite a bit
Extremely
Fatigue
1
2
3
4
5
Pain
6
7
8
9
10
Problems with memory
11
12
13
14
15
Difficulty concentrating
16
17
18
19
20
Mood changes
21
22
23
24
25
Sleep disturbances
26
27
28
29
30
How would you rate your physical functioning over the past week?
*
1
2
3
4
5
How often have you felt emotionally well in the past week?
*
Always
Often
Sometimes
Rarely
Never
How much have your neurological symptoms limited your ability to participate in social activities?
*
Not at all
1
2
3
4
Completely
5
1 is Not at all, 5 is Completely
Do you require assistance with any of the following daily activities? (Select all that apply)
*
Walking or mobility
Dressing or grooming
Eating or preparing food
Bathing
None of the above
Please describe any other symptoms or concerns you have experienced.
Overall, how would you rate your quality of life in the past week?
*
1
2
3
4
5
6
7
8
9
10
Submit Questionnaire
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