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Form Approved
OMB No. 0920-0904
Exp. Date 11/30/2014

(affix label here)
Patient ID
Number

Site

PedsQL

Sub-site

Sequential ID

™

Pediatric Quality of Life
Inventory
Version 4.0

PARENT REPORT for TODDLERS (ages 2-4)

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.

Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN:
PRA (0920-0904).
PedsQL 4.0 Parent (2-4))
(05/01/02, Version 1, 11:05 AM)

Not to be reproduced without permission

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

2. Running

3. Participating in active play or exercise

4. Lifting something heavy

5. Bathing

6. Helping to pick up his or her toys

7. Having hurts or aches

8. Low energy level

Never

Almost
Never

Sometimes

Often

Almost
Always

1. Feeling afraid or scared

2. Feeling sad or blue

3. Feeling angry

4. Trouble sleeping

5. Worrying

Never

Almost
Never

Sometimes

Often

Almost
Always

1. Playing with other children

2. Other kids not wanting to play with him or her

3. Getting teased by other children

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

5. Keeping up when playing with other children

Sometimes

Often

Never

Almost
Always

PHYSICAL FUNCTIONING (problems with…)

EMOTIONAL FUNCTIONING (problems with…)

SOCIAL FUNCTIONING (problems with…)

*Please complete this section if your child attends school or daycare
Never
Almost
SCHOOL FUNCTIONING (problems with…)
1. Doing the same school activities as peers

2. Missing school/daycare because of not feeling well

3. Missing school/daycare to go to the doctor or
hospital

PedsQL 4.0 Parent (2-4))
(05/01/02, Version 1, 11:05 AM)

Not to be reproduced without permission

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 (2-4))
(05/01/02, Version 1, 11:05 AM)

Day

Year

Reviewer
Code
Data Entry
Code

Not to be reproduced without permission

Form Approved
OMB No. 0920-0904
Exp. Date 11/30/2014

(affix label here)
Patient ID
Number

Site

Sub-site

Sequential ID

™

PedsQL

Pediatric Quality of Life
Inventory
Version 4.0
YOUNG CHILD REPORT (ages 5-7)

Instructions for interviewer:
I am going to ask you some questions about things that might be a problem for some
children. I want to know how much of a problem any of these things might be for you.
Show the child the template and point to the responses as you read.
If it is not at all a problem for you, point to the smiling face
If it is sometimes a problem for you, point to the middle face
If it is a problem for you a lot, point to the frowning face
I will read each question. Point to the pictures to show me how much of a problem it is for
you. Let’s try a practice one first.

Is it hard for you to snap your fingers

Not at all

Sometimes

A lot







Ask the child to demonstrate snapping his or her fingers to determine whether or not the question
was answered correctly. Repeat the question if the child demonstrates a response that is different
from his or her action.
Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN:
PRA (0920-0904).
PedsQL 4.0 Child (5-7)
(05/01/02, Version 1, 11:00 AM)

Not to be reproduced without permission

PedsQL 2

Think about how you have been doing for the last few weeks. Please listen carefully to each
sentence and tell me how much of a problem this is for you.
After reading the item, gesture to the template. If the child hesitates or does not seem to understand how to
answer, read the response options while pointing at the faces.

PHYSICAL FUNCTIONING (problems with…)
1.
2.
3.
4.
5.
6.
7.
8.

Is it hard for you to walk
Is it hard for you to run
Is it hard for you to play sports or exercise
Is it hard for you to pick up big things
Is it hard for you to take a bath or shower
Is it hard for you to do chores (like pick up your toys)
Do you have hurts or aches (Where?___________ )
Do you ever feel too tired to play

Not
at all

Sometimes

A lot

0
0
0
0
0
0
0
0

2
2
2
2
2
2
2
2

4
4
4
4
4
4
4
4

Remember, tell me how much of a problem this has been for you for the last few weeks.
Not
SomeA lot
EMOTIONAL FUNCTIONING (problems with…)

1.
2.
3.
4.
5.

Do you feel scared
Do you feel sad
Do you feel mad
Do you have trouble sleeping
Do you worry about what will happen to you

SOCIAL FUNCTIONING (problems with…)
1.
2.
3.
4.
5.

Is it hard for you to get along with other kids
Do other kids say they do not want to play with you
Do other kids tease you
Can other kids do things that you cannot do
Is it hard for you to keep up when you play with other
kids

SCHOOL FUNCTIONING (problems with…)
1.
2.
3.
4.
5.

Is it hard for you to pay attention in school
Do you forget things
Is it hard to keep up with schoolwork
Do you miss school because of not feeling good
Do you miss school because you have to go to the
doctor’s or hospital

PedsQL 4.0 Child (5-7)
(05/01/02, Version 1, 11:00 AM)

at all

times

0
0
0
0
0

2
2
2
2
2

4
4
4
4
4

Not
at all

Sometimes

A lot

0
0
0
0

2
2
2
2

4
4
4
4

Not
at all

Sometimes

A lot

0
0
0
0

2
2
2
2

4
4
4
4

Not to be reproduced without permission

PedsQL 3

FOR STUDY USE ONLY
Date Completed

Completed by
Month

Day

Year

Date Reviewed
Month

Day

Year

Date Entered
Month

PedsQL 4.0 Child (5-7)
(05/01/02, Version 1, 11:00 AM)

Day

Year

Reviewer
Code
Data Entry
Code

Not to be reproduced without permission

How much of a problem is this for you?

Not at all

Sometimes

A lot







PedsQL 4.0 Child (5-7)
(04/25/02, Version 1, 11:00 AM)

Not to be reproduced without permission

Form Approved
OMB No. 0920-0904
Exp. Date 11/30/2014

(affix label here)
Patient ID
Number

Site

Sub-site

PedsQL

Sequential ID

™

Pediatric Quality of Life
Inventory
Version 4.0

CHILD REPORT (ages 8-12)

DIRECTIONS
On the following page is a list of things that might be a problem for you.
Please tell us how much of a problem each one has been for you
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.

Not to be reproduced without permission

PedsQL 2

In the past ONE month, how much of a problem has this been for you …
Never

Almost
Never

Sometimes

Often

Almost
Always

1. It is hard for me to walk more than one block

2. It is hard for me to run

3. It is hard for me to do sports activity or exercise

4. It is hard for me to lift something heavy

5. It is hard for me to take a bath or shower by myself

6. It is hard for me to do chores around the house

7. I hurt or ache

8. I have low energy

Never

Almost
Never

Sometimes

Often

Almost
Always

1. I feel afraid or scared

2. I feel sad or blue

3. I feel angry

4. I have trouble sleeping

5. I worry about what will happen to me

Never

Almost
Never

Sometimes

Often

Almost
Always

1. I have trouble getting along with other kids

2. Other kids do not want to be my friend

3. Other kids tease me

4. I cannot do things that other kids my age can do

5. It is hard to keep up when I play with other kids

ABOUT SCHOOL (problems with…)

Never

Almost
Never

Sometimes

Often

Almost
Always

1. It is hard to pay attention in class

2. I forget things

3. I have trouble keeping up with my schoolwork

4. I miss school because of not feeling well

5. I miss school to go to the doctor or hospital

ABOUT MY HEALTH AND ACTIVITIES (problems with…)

ABOUT MY FEELINGS (problems with…)

HOW I GET ALONG WITH OTHERS (problems with…)

PedsQL 4.0 Child (8-12))
(05/01/02, Version 1, 11:04 AM)

Not to be reproduced without permission

PedsQL 3

FOR STUDY USE ONLY
Date Completed

Completed by
Month

Day

Year

Date Reviewed
Month

Day

Year

Date Entered
Month

PedsQL 4.0 Child (8-12))
(05/01/02, Version 1, 11:04 AM)

Day

Year

Reviewer
Code
Data Entry
Code

Not to be reproduced without permission

Form Approved
OMB No. 0920-0904
Exp. Date 11/30/2014

(affix label here)
Patient ID
Number

Site

Sub-site

PedsQL

Sequential ID

™

Pediatric Quality of Life
Inventory
Version 4.0

TEEN REPORT (ages 13-18)

Not to be reproduced without permission

PedsQL 2

In the past ONE month, how much of a problem has this been for you …
Never

Almost
Never

Sometimes

Often

Almost
Always

1. It is hard for me to walk more than one block

2. It is hard for me to run

3. It is hard for me to do sports activity or exercise

4. It is hard for me to lift something heavy

5. It is hard for me to take a bath or shower by myself

6. It is hard for me to do chores around the house

7. I hurt or ache

8. I have low energy

Never

Almost
Never

Sometimes

Often

Almost
Always

1. I feel afraid or scared

2. I feel sad or blue

3. I feel angry

4. I have trouble sleeping

5. I worry about what will happen to me

Never

Almost
Never

Sometimes

Often

Almost
Always

1. I have trouble getting along with other teens

2. Other teens do not want to be my friend

3. Other teens tease me

4. I cannot do things that other teens my age can do

5. It is hard to keep up with my peers

ABOUT SCHOOL (problems with…)

Never

Almost
Never

Sometimes

Often

Almost
Always

1. It is hard to pay attention in class

2. I forget things

3. I have trouble keeping up with my schoolwork

4. I miss school because of not feeling well

5. I miss school to go to the doctor or hospital

ABOUT MY HEALTH AND ACTIVITIES (problems with…)

ABOUT MY FEELINGS (problems with…)

HOW I GET ALONG WITH OTHERS (problems with…)

PedsQL 4.0 - (13-18)
05/01/02

Not to be reproduced without permission

PedsQL 3

FOR STUDY USE ONLY
Date Completed

Completed by
Month

Day

Year

Date Reviewed
Month

Day

Year

Date Entered
Month

PedsQL 4.0 - (13-18)
05/01/02

Day

Year

Reviewer
Code
Data Entry
Code

Not to be reproduced without permission

Form Approved
OMB No. 0920-0904
Exp. Date 11/30/2014

(affix label here)
Patient ID
Number

Site

Sub-site

PedsQL

Sequential ID

™

Pediatric Quality of Life
Inventory
Version 4.0

YOUNG ADULT REPORT (age 19 or older)

Not to be reproduced without permission

PedsQL 2

In the past ONE month, how much of a problem has this been for you …
Never

Almost
Never

Sometimes

Often

Almost
Always

1. It is hard for me to walk more than one block

2. It is hard for me to run

3. It is hard for me to do sports activity or exercise

4. It is hard for me to lift something heavy

5. It is hard for me to take a bath or shower by myself

6. It is hard for me to do chores around the house

7. I hurt or ache

8. I have low energy

Never

Almost
Never

Sometimes

Often

Almost
Always

1. I feel afraid or scared

2. I feel sad or blue

3. I feel angry

4. I have trouble sleeping

5. I worry about what will happen to me

HOW I GET ALONG WITH OTHERS (problems with…)

Never

Almost
Never

Sometimes

Often

Almost
Always

1. I have trouble getting along with other people my age

2. Other people my age do not want to be my friend

3. Other people my age tease me

4. I cannot do things that other people my age can do

5. It is hard to keep up with other people my age

ABOUT SCHOOL OR WORK (problems with…)

Never

Almost
Never

Sometimes

Often

Almost
Always

1. It is hard to pay attention in class or at work

2. I forget things

3. I have trouble keeping up with my schoolwork or work
assignments
4. I miss school or work because of not feeling well

5. I miss school or work to go to the doctor or hospital

ABOUT MY HEALTH AND ACTIVITIES (problems with…)

ABOUT MY FEELINGS (problems with…)

PedsQL 4.0 Young Adult
(05/01/02, Version 1, 11:12 AM)

Not to be reproduced without permission

PedsQL 3

FOR STUDY USE ONLY
Date Completed

Completed by
Month

Day

Year

Date Reviewed
Month

Day

Year

Date Entered
Month

PedsQL 4.0 Young Adult
(05/01/02, Version 1, 11:12 AM)

Day

Year

Reviewer
Code
Data Entry
Code

Not to be reproduced without permission

Form Approved
OMB No. 0920-0904
Exp. Date 11/30/2014

(affix label here)
Patient ID
Number

Site

Sub-site

PedsQL

Sequential ID

™

Pediatric Quality of Life
Inventory
Version 4.0

PARENT REPORT for YOUNG CHILDREN (ages 5-7)

Not to be reproduced without permission

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

2. Running

3. Participating in sports activity or exercise

4. Lifting something heavy

5. Taking a bath or shower by him or herself

6. Doing chores, like picking up his or her toys

7. Having hurts or aches

8. Low energy level

Never

Almost
Never

Sometimes

Often

Almost
Always

1. Feeling afraid or scared

2. Feeling sad or blue

3. Feeling angry

4. Trouble sleeping

5. Worrying about what will happen to him or her

Never

Almost
Never

Sometimes

Often

Almost
Always

1. Getting along with other children

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

3. Getting teased by other children

Never

Almost
Never

Sometimes

Often

Almost
Always

1. Paying attention in class

2. Forgetting things

3. Keeping up with school activities

4. Missing school because of not feeling well

5. Missing school to go to the doctor or hospital

PHYSICAL FUNCTIONING (problems with…)

EMOTIONAL FUNCTIONING (problems with…)

SOCIAL FUNCTIONING (problems with…)

4. Not able to do things that other children his or
her age can do
5. Keeping up when playing with other children

SCHOOL FUNCTIONING (problems with…)

PedsQL 4.0 Parent (5-7))
(05/01/02, Version 1, 11:06 AM)

Not to be reproduced without permission

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 (5-7))
(05/01/02, Version 1, 11:06 AM)

Day

Year

Reviewer
Code
Data Entry
Code

Not to be reproduced without permission

Form Approved
OMB No. 0920-0904
Exp. Date 11/30/2014

(affix label here)
Patient ID
Number

Site

PedsQL

Sub-site

Sequential ID

™

Pediatric Quality of Life
Inventory
Version 4.0

PARENT REPORT for CHILDREN (ages 8-12)

Not to be reproduced without permission

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

2. Running

3. Participating in sports activity or exercise

4. Lifting something heavy

5. Taking a bath or shower by him or herself

6. Doing chores around the house

7. Having hurts or aches

8. Low energy level

Never

Almost
Never

Sometimes

Often

Almost
Always

1. Feeling afraid or scared

2. Feeling sad or blue

3. Feeling angry

4. Trouble sleeping

5. Worrying about what will happen to him or her

Never

Almost
Never

Sometimes

Often

Almost
Always

1. Getting along with other children

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

3. Getting teased by other children

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

5. Keeping up when playing with other children

Never

Almost
Never

Sometimes

Often

Almost
Always

1. Paying attention in class

2. Forgetting things

3. Keeping up with schoolwork

4. Missing school because of not feeling well

5. Missing school to go to the doctor or hospital

PHYSICAL FUNCTIONING (problems with…)

EMOTIONAL FUNCTIONING (problems with…)

SOCIAL FUNCTIONING (problems with…)

SCHOOL FUNCTIONING (problems with…)

PedsQL 4.0 Parent (8-12))
(05/01/02, Version 1, 11:08 AM)

Not to be reproduced without permission

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))
(05/01/02, Version 1, 11:08 AM)

Day

Year

Reviewer
Code
Data Entry
Code

Not to be reproduced without permission

Form Approved
OMB No. 0920-0904
Exp. Date 11/30/2014

(affix label here)
Patient ID
Number

Site

PedsQL

Sub-site

Sequential ID

™

Pediatric Quality of Life
Inventory
Version 4.0

PARENT REPORT for TEENS (ages 13-18)

DIRECTIONS
On the following page is a list of things that might be a problem for your teen.
Please tell us how much of a problem each one has been for your teen
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.

Not to be reproduced without permission

PedsQL 2

In the past ONE month, how much of a problem has your teen had with …
Never

Almost
Never

Sometimes

Often

Almost
Always

1. Walking more than one block

2. Running

3. Participating in sports activity or exercise

4. Lifting something heavy

5. Taking a bath or shower by him or herself

6. Doing chores around the house

7. Having hurts or aches

8. Low energy level

Never

Almost
Never

Sometimes

Often

Almost
Always

1. Feeling afraid or scared

2. Feeling sad or blue

3. Feeling angry

4. Trouble sleeping

5. Worrying about what will happen to him or her

Never

Almost
Never

Sometimes

Often

Almost
Always

1. Getting along with other teens

2. Other teens not wanting to be his or her friend

3. Getting teased by other teens

4. Not able to do things that other teens his or her age
can do
5. Keeping up with other teens

Never

Almost
Never

Sometimes

Often

Almost
Always

1. Paying attention in class

2. Forgetting things

3. Keeping up with schoolwork

4. Missing school because of not feeling well

5. Missing school to go to the doctor or hospital

PHYSICAL FUNCTIONING (problems with…)

EMOTIONAL FUNCTIONING (problems with…)

SOCIAL FUNCTIONING (problems with…)

SCHOOL FUNCTIONING (problems with…)

PedsQL 4.0 - Parent (13-18)
05/01/02

Not to be reproduced without permission

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 (13-18)
05/01/02

Day

Year

Reviewer
Code
Data Entry
Code

Not to be reproduced without permission

File Type	application/pdf
Author	Psychiatry Department
File Modified	2014-02-05
File Created	2014-02-05