005_Sickle Cell_Pe 005_Sickle Cell_PedsQL_Parents_kids5-7

PedsQL 2

ID# __________________________

Date:_________________________

PedsQL ^™

Pediatric Quality of Life

Inventory

Version 4.0

PARENT REPORT for YOUNG CHILDREN (ages 5-7)

DIRECTIONS

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 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 child 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, like picking up his or her toys	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 children	0	1	2	3	4
2. Other kids not wanting to be his or her friend	0	1	2	3	4
3. Getting teased by other children	0	1	2	3	4
4. Not able to do things that other children his or her age can do	0	1	2	3	4
5. Keeping up when playing with other children	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 school activities	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 (5-7) Not to be reproduced without permission Copyright © 1998 JW Varni, Ph.D. All rights reserved

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PedsQL-4.0-Core – US/English

PedsQL-4.0-Core-PYC_eng-USori.doc