Quality of Life Questionaire
Demographics
Case Number
Full Name
First Name
Middle Name
Last Name
Date of Interview
Location of Interview
Name of Interviewer
Title of Interviewer
Race/Ethnicity
Please Select
Caucasian
African American
Asian
Hispanic
Native American
Other
Members in Household
Father or Step Father
Mother or Step Mother
Siblings
Other
Child's Date of Birth
Child's Gender
Primary Language
Mother's Education
Less than High School
Completed High School
Some College
4 Year Degree
Graduate Degree
Father's Education
Less than High School
Completed High School
Some College
4 Year Degree
Graduate Degree
Areas of Development
Rate how much of a problem the child has in each area of development
1= Not a problem 2=Somewhat of a problem 3= Mild Problem 4=Moderate Problem 5=Severe Problem
Social Skills
1
2
3
4
5
Communication Skills
1
2
3
4
5
Fine Motor Skills
1
2
3
4
5
Gross Motor Skills
1
2
3
4
5
Cognitive Skills
1
2
3
4
5
Adaptive Skills
1
2
3
4
5
Play Skills
1
2
3
4
5
Estimate the age that the target child acquired the following developmental milestones/skills
Walk
Sit up on his/her own, without support
2-Word Sentences
Toilet Trained
Grasp Objects
Drink from a cup
How easy or hard is it for you to complete daily living activities with the child
Feeding
1
2
3
4
5
Easy
Very Hard
1 is Easy, 5 is Very Hard
How easy or difficult is mealtime for the child
1
2
3
4
5
easy
very difficult
1 is easy, 5 is very difficult
How easy or hard is mealtime for your family?
1
2
3
4
5
Easy
Hard
1 is Easy, 5 is Hard
Bathing
1
2
3
4
5
Easy
Very Hard
1 is Easy, 5 is Very Hard
Dressing
1
2
3
4
5
Easy
Very Hard
1 is Easy, 5 is Very Hard
Behavioral Issues
Rate how often the child uses the following skills and behaviors to tell that he/she does not want something?
1=Always Uses 2= Often Uses 3=Sometime Uses 4=rarely uses 5=Never Uses
Talks/uses words
1
2
3
4
5
Use Gestures/Points
1
2
3
4
5
Uses Sign Language
1
2
3
4
5
Looks at what he/she wants
1
2
3
4
5
Cries
1
2
3
4
5
Submit
Should be Empty: