005_Sickle Cell_Pe 005_Sickle Cell_PedsQL_Parents_Teens

PedsQL 2

ID#__________________________

Date:________________________

PedsQL ^™

Pediatric Quality of Life

Inventory

Version 4.0

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.

In the past ONE month, how much of a problem has your teen had with …

Physical Functioning (problems with…)	Never	Almost Never	Some-times	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. Taking a bath or shower by him or herself	0	1	2	3	4
6. Doing chores around the house	0	1	2	3	4
7. Having hurts or aches	0	1	2	3	4
8. Low energy level	0	1	2	3	4

Emotional Functioning (problems with…)	Never	Almost Never	Some-times	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. Trouble sleeping	0	1	2	3	4
5. Worrying about what will happen to him or her	0	1	2	3	4

Social Functioning (problems with…)	Never	Almost Never	Some-times	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
4. Not able to do things that other teens his or her age can do	0	1	2	3	4
5. Keeping up with other teens	0	1	2	3	4

School Functioning (problems with…)	Never	Almost Never	Some-times	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
4. Missing school because of not feeling well	0	1	2	3	4
5. Missing school to go to the doctor or hospital	0	1	2	3	4

PedsQL 4.0 - Parent (13-18) Not to be reproduced without permission Copyright © 1998 JW Varni, Ph.D. All rights reserved

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