Salud Integral Treatment procedures

Quality of Life Questionnaire

Please complete the questionnaire below as required.
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QUALITY OF LIFE SCALE

On a scale of 0 to 10, with 0 being such poor quality of life that it would not be worth continuing to live, and 10 being the best quality of life you have ever had, at what number would you rate the following?

Quality of life the past day.*

Please enter a number from 0 to 10

Quality of life the past 7 days.*

Please enter a number from 0 to 10

Quality of life the past month.*

Please enter a number from 0 to 10

PAIN SCALE

On a scale of 0 to 10, 0 being no pain, and 10 being the worst pain you have ever had in your life, at what level is your pain at this moment? *

Please enter a number between 0 and 10

Using the same scale, what has been your average pain level in:

The past 24 hours*

Please enter a number between 0 and 10

The past week*

Please enter a number between 0 and 10

The past month*

Please enter a number between 0 and 10

Would you say that your amount of pain medicine over the past month has: *

IncreasedDecreasedStayed the same

Please make a selection

Please enter weight in kg or lbs." for="normalWeight">What is your normal weight?*

Please enter your normal weight here

Please enter weight in kg or lbs." for="currentWeight">What is your current weight?*

Please enter your current weight here

Please list all medications you are currently taking below

Medication

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Additional comments

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Quality of Life Questionnaire

PHYSICAL WELL BEING

EMOTIONAL WELL BEING

FUNCTIONAL WELL BEING

QUALITY OF LIFE SCALE

PAIN SCALE

PHYSICAL WELL BEING

EMOTIONAL WELL BEING

SOCIAL/FAMILY WELL BEING

FUNCTIONAL WELL BEING

QUALITY OF LIFE SCALE

PAIN SCALE