Pediatric Quality of Life (child) (Parent)

Longitudinal follow-up of Youth with Attention-Deficit/Hyperactivity Disorder identified in Community Settings: Examining Health Status, Correlates, and Effects associated with treatment for ADHD

Attachment B15 Parent Pediatric Quality of Life Child (8-12) scan

Attachment B15. Pediatric Quality of Life (child) (Parent)

OMB: 0920-0747

Document [doc]
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Pediatric Quality of Life

(Parent Report for Children Ages 8-12)


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

_____________________






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

  1. Walking more than one block

O

O

O

O

O

  1. Running

O

O

O

O

O

  1. Participating in sports activity or exercise

O

O

O

O

O

  1. Lifting something heavy

O

O

O

O

O

  1. Taking a bath or shower by him or herself

O

O

O

O

O

  1. Doing chores around the house

O

O

O

O

O

  1. Having hurts or aches

O

O

O

O

O

  1. Low energy level

O

O

O

O

O


Emotional Functioning (problems with…)

Never

Almost Never

Some-times

Often

Almost Always

  1. Feeling afraid or scared

O

O

O

O

O

  1. Feeling sad or blue

O

O

O

O

O

  1. Feeling angry

O

O

O

O

O

  1. Trouble sleeping

O

O

O

O

O

  1. 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

  1. Getting along with other children

O

O

O

O

O

  1. Other kids not wanting to be his or her friend

O

O

O

O

O

  1. Getting teased by other children

O

O

O

O

O

  1. Not being able to do things that other children his or her age can do

O

O

O

O

O

  1. Keeping up when playing with other children

O

O

O

O

O

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 (???).

Please 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

  1. Paying attention in class

O

O

O

O

O

  1. Forgetting things

O

O

O

O

O

  1. Keeping up with schoolwork

O

O

O

O

O

  1. Missing school because of not feeling well

O

O

O

O

O

  1. Missing school to go to the doctor or hospital

O

O

O

O

O

The End.


































File Typeapplication/msword
File TitlePedsQL
AuthorGaramsey
Last Modified ByAngelika Claussen
File Modified2007-03-23
File Created2006-10-23

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