Quality of Life Scale (Q-LES-Q-SF)

Your Name Client Code (provided by your therapist)

Question 1 of 16

Taking everything into consideration, during the past week how satisfied have you been with your physical health?

Very Poor Poor Fair Good Very Good

Question 2 of 16

Taking everything into consideration, during the past week how satisfied have you been with your mood?

Very Poor Poor Fair Good Very Good

Question 3 of 16

Taking everything into consideration, during the past week how satisfied have you been with your work?

Very Poor Poor Fair Good Very Good

Question 4 of 16

Taking everything into consideration, during the past week how satisfied have you been with your household activities?

Very Poor Poor Fair Good Very Good

Question 5 of 16

Taking everything into consideration, during the past week how satisfied have you been with your social relationships?

Very Poor Poor Fair Good Very Good

Question 6 of 16

Taking everything into consideration, during the past week how satisfied have you been with your family relationships?

Very Poor Poor Fair Good Very Good

Question 7 of 16

Taking everything into consideration, during the past week how satisfied have you been with your leisure time activities?

Very Poor Poor Fair Good Very Good

Question 8 of 16

Taking everything into consideration, during the past week how satisfied have you been with your ability to function in daily life?

Very Poor Poor Fair Good Very Good

Question 9 of 16

Taking everything into consideration, during the past week how satisfied have you been with your sexual drive, interest and/or performance?

Very Poor Poor Fair Good Very Good

Question 10 of 16

Taking everything into consideration, during the past week how satisfied have you been with your economic status?

Very Poor Poor Fair Good Very Good

Question 11 of 16

Taking everything into consideration, during the past week how satisfied have you been with your living/housing situation?

Very Poor Poor Fair Good Very Good

Question 12 of 16

Taking everything into consideration, during the past week how satisfied have you been with your ability to get around physically without feeling dizzy or unsteady or falling?

Very Poor Poor Fair Good Very Good

Question 13 of 16

Taking everything into consideration, during the past week how satisfied have you been with your vision in terms of ability to do work or hobbies?

Very Poor Poor Fair Good Very Good

Question 14 of 16

Taking everything into consideration, during the past week how satisfied have you been with your overall sense of well-being?

Very Poor Poor Fair Good Very Good

Question 15 of 16

Taking everything into consideration, during the past week how satisfied have you been with your medication? (If not taking any medication, leave this item blank)

Very Poor Poor Fair Good Very Good

Question 16 of 16

Taking everything into consideration, during the past week how would you rate your overall life satisfaction and contentment?

Very Poor Poor Fair Good Very Good

Your responses are confidential.

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