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In the past ONE month, how much of a problem has your child had with …
Never
Almost
Never
Sometimes
Often
Almost
Always
1. Walking more than one block
0
1
2
3
4
2. R unning
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. D oing chores around the house
0
1
2
3
4
7. H aving hurts or aches
0
1
2
3
4
8. Low energy level
0
1
2
3
4
Never
Almost
Never
Sometimes
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
Never
Almost
Never
Sometimes
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
Never
Almost
Never
Sometimes
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 schoolwork
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
PHYSICAL FUNCTIONING (problems with…)
EMOTIONAL FUNCTIONING (problems with…)
SOCIAL FUNCTIONING (problems with…)
SCHOOL FUNCTIONING (problems with…)
PedsQL 4.0 Parent (8-12))
Varni, Ph.D.
(05/01/02, Version 1, 12:32 PM)
Not to be reproduced without permission
All rights reserved
Copyright © 1998 JW
PedsQL 3
FOR STUDY USE ONLY
Date Completed
Completed by
Month
Day
Year
Date Reviewed
Month
Day
Year
Date Entered
Month
PedsQL 4.0 Parent (8-12))
Varni, Ph.D.
(05/01/02, Version 1, 12:32 PM)
Day
Year
Reviewer
Code
Data Entry
Code
Not to be reproduced without permission
All rights reserved
Copyright © 1998 JW
| File Type | application/pdf |
| File Title | PedsQL Parent Report for Age 8-12.doc |
| Author | kwilson |
| File Modified | 2011-05-10 |
| File Created | 2002-05-06 |