Pediatric Quality of Life (young child) (Parent)

P

OMB No: ???: Exp Date: ???

_____________________

ediatric Quality of Life

(Parent Report for Young Children Ages 5-7)

On the following page is a list of things that might be a problem for your child. Please tell us how much of a problem each one has been for your child during the past ONE month by filling in the circle for never a problem, almost never a problem, sometimes a problem, often a problem, or almost always a problem. There are no right or wrong answers. If you do not understand a question, please ask for help. Please begin now. Thank you.

Physical Functioning (problems with…)	Never	Almost Never	Some-times	Often	Almost Always
Walking more than one block	O	O	O	O	O
Running	O	O	O	O	O
Participating in sports activity or exercise	O	O	O	O	O
Lifting something heavy	O	O	O	O	O
Taking a bath or shower by him or herself	O	O	O	O	O
Doing chores, like picking up his or her toys	O	O	O	O	O
Having hurts or aches	O	O	O	O	O
Low energy level	O	O	O	O	O

Emotional Functioning (problems with…)	Never	Almost Never	Some-times	Often	Almost Always
Feeling afraid or scared	O	O	O	O	O
Feeling sad or blue	O	O	O	O	O
Feeling angry	O	O	O	O	O
Trouble sleeping	O	O	O	O	O
Worrying about what will happen to him or her	O	O	O	O	O

Social Functioning (problems with…)	Never	Almost Never	Some-times	Often	Almost Always
Getting along with other children	O	O	O	O	O
Other kids not wanting to be his or her friend	O	O	O	O	O
Getting teased by other children	O	O	O	O	O
Not being able to do things that other children his or her age can do	O	O	O	O	O
Keeping up when playing with other children	O	O	O	O	O

P

Public reporting burden of this collection of information is estimated to average 4 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Clearance Officer; 1600 Clifton Road NE, MS D-24, Atlanta, Georgia 30333; ATTN: PRA (???).

lease turn over and answer questions on back of page.

FOR STUDY USE ONLY
ID Number
Date Interviewed	Month Day Year	Interviewed by

School Functioning (problems with…)	Never	Almost Never	Some-times	Often	Almost Always
Paying attention in class	O	O	O	O	O
Forgetting things	O	O	O	O	O
Keeping up with school activities	O	O	O	O	O
Missing school because of not feeling well	O	O	O	O	O
Missing school to go to the doctor or hospital	O	O	O	O	O

The End.