Quality of Life Enjoyment and Satisfaction Questionnaire – Short Form

(Q-LES-Q-SF)

Taking everything into consideration, during the past week how satisfied have you been with your………

 

Very Poor

Poor

Fair

Good

Very Good

…..physical health?

…..mood?

…..work?

…..household activities?

…..social relationships?

…..family relationships?

…..leisure time activities?

…..ability to function in daily life?

…..sexual drive, interest and/or

 

 

 

 

 

performance?*

…..economic status?

…..living/housing situation?*

…..ability to get around physically

 

 

 

 

 

without feeling dizzy or unsteady

 

 

 

 

 

or falling?*

…..your vision in terms of ability to do

 

 

 

 

 

work or hobbies?*

…..overall sense of well being?

…..medication? (If not taking any,

 

 

 

 

 

check here _____ and leave item

 

 

 

 

 

blank.)

…..How would you rate your overall life

 

 

 

 

 

satisfaction and contentment during

 

 

 

 

 

the past week?

Total = ______