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PedsQL 2

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 Typeapplication/pdf
File TitlePedsQL Parent Report for Age 8-12.doc
Authorkwilson
File Modified2011-05-10
File Created2002-05-06

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