SunflowerCentre Logo

THE HEALTH RELATED QUALITY OF LIFE IN STROKE PATIENTS

Introductions

This assessment asks about how you perceive your current state of health, quality of life, or other areas
of your life.Please answer all the questions honestly.If you are unsure about what response to give to a question,
please choose the nearest most appropriate response.
Please keep in mind your standards, hopes, pleasures, and concerns.Think about your life in the last two weeks.

>
SECTION A: PHYSICAL DOMAIN
NOTE:0=Nil, 1=flicker, 2=gravity eliminated, 
3=against gravity, 4=against resistance,  5=normal
Best motor power in the dexterous hand/upper limb
Best motor in the affected upper limb
Best motor power effect in affected lower limb
For the next question
0=Nil, 1=present
Speech defect [aphasia]
For Mobility 1=Bed bound, 2=Chair bound, 
3=Walks with helpers, 4=Walks with aids[frame/tripod],   5=Walks unaided
Mobility
For the following questions 1=Not at all, 2=A little, 
3=A moderate amount,  4=Very much,  5=Extremely
To what extent do you have difficulties gripping objects,
turning door-knob, using cutlery, writing, opening jar/can, carrying heavy objects?
To what extent do you have difficulties controlling your bladder/bowels?
To what extent do you have difficulties sitting/standing without losing your balance?
To what extent do you have difficulties seeing objects off to one side/reaching for objects because of poor eyesight?
To what extent do you think physical pain/discomfort/abnormal sensation/absent sensation prevent you from doing what you need to?
How much do you need any medical treatment [drugs or aids]
and/or hospital attendance to function in your daily life?
To what extent has your sex life been adversely affected?
Note: 1=Very dissatisfied, 2=Dissatisfied, 
3=Neither satisfied nor dissatisfied, 4=Satisfied,  5=Very satisfied
How satisfied are you with your ability to perform your
daily living activities [feeding, bathing, toileting, dressing, grooming, e.t.c.]?
How satisfied are you with your capacity for work?
How satisfied are you with your sex life?
Note: 1=Not at all, 2=A little, 
3=Moderately, 4=Very much,   5=Extremely
How important to you are the aspects of your life covered in this section?
SECTION B: PSYCHOLOGICAL DOMAIN
Note: 1=Not at all/Never,  2=A little/seldom, 
3=Moderately/Quite often,   4=Mostly/Very often,  5=Completely/Always
How often do you have negative feelings such as blue mood, anger,
despair, anxiety, depression, fear?
Do you have enough energy for everyday life?
To what extent are you able to accept your bodily appearance?
To what extent do you enjoy your work?
How often do you laugh?
To what extent do you enjoy recreation/
pastimes/leisure/rest /relaxation?
How safe do you feel in your daily life?
To what extent have you ever felt death to be better than your present condition?
To what extent have you ever felt like ending your life?
Note: 1=Very dissatisfied,  2=Dissatisfied,  
3=Neither satisfied nor dissatisfied,   4=Satisfied,  5=Very satisfied
How satisfied are you with your sleep [duration and quality]?
How satisfied are you with your feelings?
Note:1=Not at all,   2=A little,  
3=Moderately,   4=Very much,   5=Extremely
How important to you are the aspects of your life covered in this section?
SECTION C: COGNITIVE DOMAIN
Note: 1=Not at all, 2=A little, 
3=Moderately,  4=Very much/Mostly, 5=Extremely/Completely
How well are you able to concentrate?
To what extent is your memory impaired?
To what extent are you able to learn new things?
To what extent do you understand your disease process?
To what extent are you able to think out/plan logical solutions
to [your] problems and take decisions?
To what extent are you able to relax your mind?
How available to you is the information that you need
for your day-to-day life?
To what extent are you able to communicate?
Note: 1=Very dissatisfied,  2=Dissatisfied,  
3=Neither satisfied nor dissatisfied,  4=Satisfied,  5=Very satisfied
How satisfied are you with your memory and ability to concentrate?
How satisfied are you with your ability to communicate?
How satisfied are you with your ability to think and learn?
Note:1=Not at all,   2=A little,  
3=Moderately,   4=Very much,   5=Extremely
How important to you are the aspects of your life covered in this section?
SECTION D: SOUL DOMAIN
Note:1=Not at all,   2=A little,   3=Moderately,  
4=Very much,   5=Extremely
How much do you value yourself?
How much confidence do you have in yourself?
How much confidence do you have in your God?
How creative are you?
To what extent are you independent and individualistic in
reasoning and taking decisions?
To what extent do you believe you have a purpose for living?
To what extent are you interested in fulfilling your purpose for living?
To what extent do you accept/ believe in destiny/predestination?
To what extent do you believe in freewill?
To what extent do you think your present condition has prevented
you from fulfilling your purpose of life?
To what extent do you think your present condition has assisted you
in fulfilling your purpose of life?
To what extents have your dreams/visions/ESP [if any] portrayed
your present condition bad?
To what extent are you intuitive/ inspired/ ingenuous?
To what extent do you rely on God to solve your problems?
To what extent do you rely on yourself to solve your problems?
To what extent do you believe the devil is responsible for your
present situation?
To what extent are you or other people responsible for your
situation more than God?
To what extent do you believe in afterlife?
To what extent do you believe in God?
To what extent do you practice your religion/faith?
To what extent do you accept your present state?
How strong is your will to live?
Note: 1=Very dissatisfied,  2=Dissatisfied, 
3=Neither satisfied nor dissatisfied,  4=Satisfied,  5=Very satisfied
To what extent are you satisfied with your faith in God?
How satisfied are you with yourself?
How satisfied are you with your abilities?
Note:1=Not at all,   2=A little,   3=Moderately,  
4=Very much,   5=Extremely
How important to you are the aspects of your life covered in this section?
SECTION E: SPIRIT DOMAIN
Note:1=Not at all,   2=A little,   3=Moderately,  
4=Very much,   5=Extremely
To what extent do you understand God?
To what extent are you guided / motivated by God in your [daily] life?
To what extent do you understand your religion/faith?
To what extent do you think God is responsible for your present state?
To what extent do you perceive your life to be meaningful?
Note: 1=Very dissatisfied,  2=Dissatisfied,  
3=Neither satisfied nor dissatisfied,  4=Satisfied,  5=Very satisfied
To what extent are you satisfied with divine guidance in your life?
Note:1=Not at all,   2=A little,   3=Moderately,  
4=Very much,   5=Extremely
How important to you are the aspects of your life covered in this section?
SECTION F: ECOSOCIAL DOMAIN
NOTE:1=Fully dependent, 2=Requires substantial help, 3=Requires minimal help, 
4=Requires no help but not back to work,   5=Back to work
Activities of daily living[feeding, bathing, toileting, etc]
NOTE: For the following questions: 1=Not at all,  2=A little, 
3=Moderately,  4=Very much,  5=Extremely/Completely
How easy is it for you to communicate with people?
How much support do you get from your relations?
How much respect do you expect from others?
How much respect do you get from others?
How much support do you get from your friends?
To what extent are you compelled by others
to do what you do not consider suitable for you?
How well are you able to meet your financial needs?
How surplus is your financial resources?
To what extent do you have access to optimal health services?
To what extent do you have access to social support?
How well are you able to manage your home and perform your domestic roles?
To what extent are you performing your occupational duties?
How healthy is your physical environment?
To what extent do you have access to transport facilities?
To what extent do you have opportunities to learn and acquire new skills?
Note: 1=Very dissatisfied  2=Dissatisfied  
3=Neither satisfied nor dissatisfied   4=Satisfied  5=Very satisfied
How satisfied are you with your personal relationships?
How satisfied are you with the support you get from your friends?
How satisfied are you with the conditions of your living place?
How satisfied are you with your access to health services?
How satisfied are you with your treatment?
How satisfied are you with your access to transportation?
Note:1=Not at all   2=A little  
3=Moderately   4=Very much   5=Extremely
How important to you are the aspects of your life covered in this section?
SECTION G: SPIRITUAL INTERACTION DOMAIN
Note: for this section 1=Not at all, 2=A little, 
3=Moderately,   4=Very much, 5=An extreme amount/completely
To what extent do you consider yourself close to God or your
object of worship?
To what extent do you meditate and/or study religious books?
To what extent do you discuss aspects of your faith/religion
with people of the same religious interest/faith in order to strengthen
your individual resolve?
Note: 1=Very dissatisfied  2=Dissatisfied  
3=Neither satisfied nor dissatisfied   4=Satisfied  5=Very satisfied
How satisfied are you with your relationship with God or your object of worship?
How satisfied are you with your effort to develop your faith/religion?
Note:1=Not at all, 2=A little, 
3=Moderately, 4=Very much,  5=Extremely
How important to you are the aspects of your life covered in the questions above?