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pdf PedsQL 2
In the past ONE month, how much of a problem has your child had with …
DIABETES (problems with…)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Feeling hungry
Feeling thirsty
Having to go to the bathroom too often
Having stomachaches
Having headaches
Going “low”
Feeling tired or fatigued
Getting shaky
Getting sweaty
Having trouble sleeping
Getting irritable
TREATMENT - I (problems with…)
1. Needle sticks (i.e. injections/blood tests) causing
him/her pain
2. Getting embarrassed about having diabetes
3. Arguing with me or my spouse about diabetes care
4. Sticking to his/her diabetes care plan
Never
Almost
Never
Sometimes
Often
Almost
Always
0
0
0
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
3
4
4
4
4
4
4
4
4
4
4
4
Never
Almost
Never
Sometimes
Often
Almost
Always
0
1
2
3
4
0
0
0
1
1
1
2
2
2
3
3
3
4
4
4
Whether your child does these things independently or with your help, please answer how
difficult these things were to do in the past ONE month. (Note: This section is not asking
about your child’s independence in these areas, just how hard they were to do).
TREATMENT - II (problems with…)
1.
2.
3.
4.
It is hard for my child to take blood glucose tests
It is hard for my child to take insulin shots
It is hard for my child to exercise
It is hard for my child to track carbohydrates or
exchanges
5. It is hard for my child to wear his/her id bracelet
6. It is hard for my child to carry a fast-acting
carbohydrate
7. It is hard for my child to eat snacks
WORRY (problems with…)
1. Worrying about “going low”
2. Worrying about whether or not medical treatments
are working
3. Worrying about long-term complications of
diabetes
PedsQL 3.0 Parent (8-12) Diabetic
(06/15/02, Version 1, 1:34 PM)
Never
Almost
Never
Sometimes
Often
Almost
Always
0
0
0
1
1
1
2
2
2
3
3
3
4
4
4
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
Never
Almost
Never
Sometimes
Often
Almost
Always
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
Not to be reproduced without permission
Copyright © 1998 JW Varni, Ph.D.
All rights reserved
PedsQL 3
In the past ONE month, how much of a problem has your child had with …
COMMUNICATION (problems with…)
1. Telling the doctors and nurses how he/she feels
2. Asking the doctors or nurses questions
3. Explaining his/her illness to other people
Never
Almost
Never
Sometimes
Often
Almost
Always
0
0
0
1
1
1
2
2
2
3
3
3
4
4
4
FOR STUDY USE ONLY
Date Completed
Completed by
Month
Day
Year
Date Reviewed
Month
Day
Year
Date Entered
Month
PedsQL 3.0 Parent (8-12) Diabetic
(06/15/02, Version 1, 1:34 PM)
Day
Year
Reviewer
Code
Data Entry
Code
Not to be reproduced without permission
Copyright © 1998 JW Varni, Ph.D.
All rights reserved
| File Type | application/pdf |
| File Title | PedsQL REVISED Parent Report for Age 8-12Diabetic.doc |
| Author | kwilson |
| File Modified | 2011-05-10 |
| File Created | 2002-06-12 |