There is no questionnaire. : _ _ _ Evaluation Date: The _ _ _ th evaluation.
Description: In order to fully understand your life quality and promote your physical and mental health, this watch is specially designed. Please answer the following questions item by item according to your actual situation in the last week (tick "√" or fill in the blanks as required). This form is anonymous and will not be published. Thank you for your cooperation.
Sex _ _ _ Age _ _ _ Years (years) Education _ _ Occupation _ _ Marriage _ _ Years (unmarried, married, widowed, divorced)
Address _ _ _ _ Zip code _ _
Health status _ _ (health, illness) (if sick, please indicate the name of the main disease)
F 1。 Per capita housing area () square meters.
F2。 Does your house have the following additional facilities? (Please tick √)
Kitchen (), bathroom (), gas (), good water supply (), good power supply ().
F3。 What do you think of the current housing conditions: (Select one)
Very satisfied (), quite satisfied (), fair (), not very satisfied (), very dissatisfied ().
F4。 Convenience of life (please tick one by one):
4. 1 Go to work (very convenient, convenient and inconvenient); 4.2 children go to school or work (very convenient, convenient and inconvenient); 4.3 Purchase daily necessities (very convenient, convenient and inconvenient); 4.4 Go to entertainment places (very convenient, convenient and inconvenient); 4.5 See a doctor (very convenient, convenient and inconvenient).
F5。 What do you think of the current community service conditions (such as convenient living and medical service conditions)?
Very satisfied (), quite satisfied (), fair (), not very satisfied (), very dissatisfied ().
F.6 environment around the house (please select one by one):
6. 1 security: unsafe (), safe (), very safe.
6.2 Greening: fewer trees (), more trees () and shady trees ().
6.3 Hygiene: very dirty (), average (), clean ().
6.4 Noise: loud, unbearable (), noisy, tolerable (), loud.
Quiet ().
F7。 What do you think of your current living environment: (choose one)
Very satisfied (), quite satisfied (), fair (), not very satisfied (), very dissatisfied ().
F8。 Food consumption accounts for about _ _% of income.
F9。 The out-of-pocket proportion of medical expenses is _ _%.
F 10 .. What is your current economic income and social welfare (including labor insurance, etc.)? ): (Select one)
Very satisfied (), quite satisfied (), fair (), not very satisfied (), very dissatisfied ().
F 1 1。 How have you slept in recent weeks? (Select one)
Never lose sleep (), occasionally (), sometimes (), often (), every night ().
F 12 ... When you woke up last morning, did you feel clear-headed, relaxed and slept well? (Select one)
Every day (), most of the time (), sometimes (), rarely (), never ().
F 13 .. How's your energy in recent weeks? (Select one)
Always energetic (), mostly energetic (), average (), often tired (), always tired ().
F 14 .. How do you feel about your sleep in recent weeks? (Select one)
Very satisfied (), quite satisfied (), fair (), not very satisfied (), very dissatisfied ().
F 15 .. How do you feel about your energy in recent weeks? (Select one)
Very dissatisfied (), dissatisfied (), passable (), quite satisfied (), very satisfied ().
F 16 .. Have you had the following physical symptoms in the past week? (such as headache, dizziness, pain in some parts of the body, gastrointestinal discomfort, indigestion, dyspnea, palpitation, cold and heat, numbness, heavy hands and feet, etc.). ) (Choose one) None (), occasionally (), sometimes (), often (), always ().
F 17 ... How serious are your above symptoms? (Select one)
None (), very light (), lighter (), heavier (), extremely heavy ().
F 18 .. Have you taken any drugs (such as painkillers, diazepam, etc.) due to physical illness or discomfort in the past week? (Select one)
Dependent on drugs (), often taking drugs (), sometimes taking drugs (), rarely taking drugs (), never taking drugs ().
F 19 .. How do you feel about your current physical health? (Select one)
Very satisfied (), quite satisfied (), fair (), not very satisfied (), very dissatisfied ().
F20 .. Compared with ordinary people, your diet in the last week is: (choose one)
Safe and normal (), basically normal (), eating less or unable to eat certain foods due to illness (), eating less or unable to eat most foods (), rarely eating ().
F2 1。 How was your appetite in the past week: (Select one)
I have no appetite at all (), poor (), average (), good (), very good ().
F22 .. What do you think of your food intake in the last week: (Choose one)
Very dissatisfied (), dissatisfied (), passable (), quite satisfied (), very satisfied ().
: F23 .. How many times have you had sex in the past week: (Choose one)
Very little (), very little or too much (), very little or too much (), basically normal (), completely normal ().
According to statistics, many people have experienced various sexual dysfunction (such as decreased sexual desire, no pleasure, impotence, premature ejaculation, etc.). ) At different times in their lives. What happened to you in the past week: (Select one)
Never (), occasionally (), sometimes (), more serious (), very serious ().
F25 .. How do you feel about your sex life in the last week? (Select one)
Very dissatisfied (), dissatisfied, passable (), relatively satisfied (), very satisfied ().
F26 .. How was your hearing and eyesight in the past week? (Select one)
Hearing and vision () are almost the same as ordinary people (), with partial decline (), severe decline (), and hearing or vision decline ().
F27 .. How was your self-care ability in the past week (including going to the toilet, eating, bathing, grooming and walking)? (Select one)
Safety can't take care of itself (), some need help (), basic self-care (), occasional difficulties (), all can take care of themselves (), agility (), freedom ().
F28 .. What is your ability to handle daily affairs (including housework, taking medicine, cycling, interacting with people, managing money, shopping, etc.)? ) In the past week? (Select one)
Take care of yourself (), without any problems (), and occasionally have difficulties, such as not being able to use transportation freely, such as not riding a bike or knocking out a car. (), part of self-care, need help (), almost impossible to do ().
F29 .. How satisfied are you with the functions of your hearing, vision and other organs at present? (Select one)
Very satisfied (), quite satisfied (), fair (), not very satisfied (), very dissatisfied ().
F30 .. What do you think of your current physical activity ability?
Very dissatisfied (), dissatisfied (), passable (), quite satisfied (), very satisfied ().
It is 1. Have you encountered the following things in your life in the past week? (such as unsatisfactory work, disharmony between husband and wife, illness of oneself or family members or death of relatives, children's problems, interpersonal tension, sudden drop in income or excessive expenditure, theft, traffic accidents, interpersonal disputes, etc.). ) (Select one)
No (), rarely (), less (), lighter (), more (), more ().
F32 .. Did you feel a heavy mental burden in the past week? Do you always feel nervous or stressed? (Select one)
None (), very light (), lighter (), heavier (), extremely heavy ().
F33 .. How nervous were you in the past week? (Select one)
Very dissatisfied (), dissatisfied (), passable (), quite satisfied (), very satisfied ().
F34 .. Have you often felt blue in the past week? What is the degree? (For example, they are unhappy, have no sense of well-being, lose energy, get tired easily, lose interest in work, entertainment and husband and wife's life, find life boring, feel lonely, cry easily, feel useless, and often blame themselves. ) (Select one)
No (), very light (), lighter (), heavier (), extremely heavy ().
F35 .. Have you often felt anxious in the past week? What is the degree? (For example: vexed for no reason or trivial matters, nervous, uneasy, afraid, flustered, short of breath, sweating, jumping muscles, etc. )? (Select one)
Extremely heavy (), heavier (), lighter (), very light (), no ().
F36 .. In the past week, did you feel that your emotions are prone to fluctuations, such as impatience, anger, sadness, etc. (Select one)
No (), very light (), lighter (), heavier (), extremely heavy ().
F37 .. In the past week, have you been in a dull mood and have no emotional response to emotions, so you don't care? (Select one)
Always like this (), most of the time (), sometimes (), rarely (), never ().
F38 .. In the past week, were you full of hope and confidence in life? Do you think living is meaningful and valuable? (Select one)
Always like this (), most of the time (), sometimes (), rarely (), never ().
F39 .. Did you feel relaxed and happy in the past week? (Select one)
Always like this (), most of the time (), sometimes (), rarely (), never ().
F40 .. How did you feel about yourself in the past week? (Select one)
Very dissatisfied (), dissatisfied (), passable (), quite satisfied (), very satisfied (). ,
F4 1。 How clear and quick were you when you were thinking or using your brain in the past week? (Select one)
Very good (), good (), average (), poor (), very poor ().
F42 .. How was your attention in the past week? (Select one)
Very poor (), poor (), average (), good (), very good ().
F43 .. If you are interested in recalling what happened in the past week, you can:
(Select one)
Remember () completely, most of them remember (), some can't remember (), most of them can't remember (), and they can't remember () at all.
F44 .. In the past week, when there was something you needed to make a decision: (Choose one)
I can't make a decision at all (), making a decision is difficult (), making a major decision is difficult (), making a decision is not difficult (), making a decision is fast and accurate ().
F45 .. Have you made a decision about your thinking, attention and memory in the past week?
How satisfied is the ability? (Select one)
Very dissatisfied (), dissatisfied (), passable (), quite satisfied (), very satisfied ().
F46 .. How do you think people around you (including society and family) treated you in the past week? (Select one)
I respect (), most respect (), average (), little respect (), and discriminate against you ().
F47 .. Your comprehensive evaluation of your talent, ability, appearance and physical condition in the past week is: (Choose one)
Very proud (), more proud (), almost the same as the average person (), not as good as others in some aspects () and not as good as others in all aspects ().
F48 .. What do you think of your current position in society and family, and what people think of you? (Select one)
Very dissatisfied (), dissatisfied (), passable (), quite satisfied (), very satisfied ().
F49 .. What do you think of your present talent and appearance? (Select one)
Very satisfied (), quite satisfied (), fair (), not very satisfied (), very dissatisfied ().
F50 .. Have you ever used certain substances (such as smoking, drinking, taking medicine, etc.)? ) to adjust their mental state (such as worry, tension, depression, etc. ) In the past week?
Never (), occasionally (), sometimes (), often (), every day ().
F5 1。 In the past week, when you needed help from others mentally or materially, what kind of support did you get from the following people (please answer one by one and tick √)?
F52 .. In the past week, when the following people needed your help, you gave them support.
Yes: (Please answer item by item and tick √)
Always get it
(2) partially available
(1) little or no.
(0)
5 1. 1 spouse (1)
5 1.2 children or parents (0.8)
5 1.3 relatives (0.4)
5 1.4 friends (0.4)
5 1.5 colleagues or neighbors, etc. (0.4)
In the past week, when the following people needed your help, you gave them support.
Yes: (Please answer item by item and tick √)
Do your best to help
(2) Can give some help.
(1) Little or no help (0)
52. 1 couple (1)
52.2 For children or parents (0.8)
52.3 pairs of relatives (0.4)
52.4 Being friends (0.4)
52.5 Being a colleague or neighbor (0.4)
F53 The help and support you received from society and family in the past week: (Select one)
Very satisfied (), quite satisfied (), fair (), not very satisfied (), very dissatisfied ().
F54 How do you feel about helping others in the past week (select one):
Very dissatisfied (), dissatisfied (), passable (), quite satisfied (), very satisfied ().
F55 In the past week, how was your relationship with the following people? (Please answer item by item, tick √)
Good, there is no contradiction.
(2) Some contradictions
(1) tension
(0)
55. 1 and children or parents (1)
55.2 Being with relatives (0.8)
55.3 with friends (0.4)
55.4 With colleagues or neighbors (0.4)
55.5 and leadership (0.4)
F56 In the past week, how often did you contact the following people (including getting along, correspondence, telephone contact, etc. Please answer item by item and tick.
Frequent contact
Nothing will come and go.
(1) little or no contact (0)
56. 1 and children or parents (1)
56.2 with relatives (o 8)
56.3 with friends (0.4)
56.4 With colleagues or neighbors (O.4)
56.5 and leadership (0.4)
F57 .. How did you deal with interpersonal relationships in the past week? (Select one)
Very satisfied (), quite satisfied (), fair (), not very satisfied (), very dissatisfied ().
F58 .. Your important news, news, etc. About the company, local and national situation in the past week: (select one)
Very concerned about (), more concerned about (), less concerned about (), less concerned about (), not at all concerned about (). F59 .. What have you learned from your life and work in the past week? (Please select one)
Always study (), sometimes study (), study under supervision (), seldom study (), not at all ().
F60 .. In the past week, your leisure time was: (Please select and fill in the specific time).
Appreciation: such as watching TV, newspapers, novels and ball games. _ _ _ _ hours/week.
Intelligence: such as playing mahjong, poker, chess and video games. _ _ _ _ hours/week.
Health care: such as running, practicing Qigong, Tai Ji Chuan, playing ball, etc. _ _ _ _ _ hours/week.
Sociality: such as dancing, meeting friends and participating in club activities. _ _ _ _ hours, weeks.
Leisure: such as walking, planting flowers, fishing, painting and calligraphy, collecting stamps, etc. _ _ _ _ hours/week.
Creativity: such as amateur novel creation, photography, etc. _ _ _ _ hours/week.
F6 1。 Compared with a week ago, what leisure activities did you have in the past week: (Select one)
Increase a lot (), slightly increase (), almost (), some decrease (), rarely ().
F62 .. What do you think of the leisure activities in the past week: (Select one)
Very satisfied (), quite satisfied (), fair (), not very satisfied (), very dissatisfied ().
F63 .. Your ability to work or your work in the past week: (Select one)
Higher than the average person (), almost the same as the average person (), slightly worse than the average person (), very poor (), losing the ability to work or work ().
F64 .. How was your work or labor efficiency in the past week? (Select one)
Always exceed (), sometimes exceed (), depending on the amount (), change to light work or complete some work or retire at home (), call in sick at home or need someone to take care of ().
F65 ... What do you think of your current work ability, work efficiency and learning ability? (Select one)
Very dissatisfied (), dissatisfied (), passable (), quite satisfied (), very satisfied ().
F66 .. Your feelings with your spouse in the past week: (If you have no spouse, please evaluate your relationship with relatives living with * * * * such as parents and children): (Select one)
Intimate (), relatively intimate (), ordinary (), relatively cold (), on the verge of rupture ().
F67 .. In the past week, when one or both spouses were in distress, they often: (If there is no spouse, please evaluate the kinship with * * * *, such as parents and children) (select one).
Never communicate (), occasionally communicate (), communicate less (), and some keep () and communicate with each other ().
F68 .. Your current family responsibilities: (If you have no spouse, please rate your relationship with your family) (Select one).
Very dissatisfied (), dissatisfied (), passable (), quite satisfied (), very satisfied ().
F69 .. The amount of housework you undertake at present (including housework, educating and raising children, taking care of parents, etc.). ) is about _ _ _ _ _ _%.
F70 .. Your current family responsibilities to yourself: (Select one)
Very satisfied (), quite satisfied (), fair (), not very satisfied (), very dissatisfied (). G 1。 How satisfied are you with your health? (Select one)
Very satisfied (), quite satisfied (), fair (), not very satisfied (), very dissatisfied ().
G2。 How satisfied are you with your life? (Select one)
Very dissatisfied (), dissatisfied (), passable (), quite satisfied (), very satisfied ().
G3。 How do you evaluate your health in recent weeks? (Select one)
Very poor (), relatively poor (), average (), relatively good (), very good ().
G4。 Your overall evaluation of your quality of life is: (Select one)
High quality (), high quality (), medium quality (), low quality (), low quality ().
Attachment: scoring method of comprehensive evaluation questionnaire for quality of life
1. Project scoring method
The score of each of the 74 projects is 1 ~ 5, some projects are positive 1 ~ 5, some projects are negative, and 5 ~ 1 is used for evaluation in statistical analysis. A few projects have several problems, which are called multi-problem projects. According to the results of our large sample research, we use the scoring formula to convert it into a positive scoring result of L ~ 5 to participate in the statistics.
(1) positive score item
F 15，F 18，F2 1，F22，F23，F25，F27，F30，F33，F35，F37，F40，F42，F44。 ，F48，F54，F65，F67，F68。
For example, F 15: you are very dissatisfied (1), dissatisfied (2), fair (3), fairly satisfied (4), very satisfied (5), and so on. (Fractions in brackets).
(2) Negative scoring items
F7 F3，F5，F 10 . 14，:F 16，F 17，F 19，F20，F24，F26，F28，F29，F3l，F34，F36，F38，F39，F4 1，F43。
For example, Fll: How have you been sleeping in recent weeks? Never insomnia (5), occasional insomnia (4), sometimes insomnia (3), frequent insomnia (2), insomnia every night (1). (Scores in brackets)
(3) Ask more scoring items
FL: 1:≤4.992:5—9.93: 10。 19.94: 40—29.95: ≥ 30m2.
F2: add 1 minute for one item, and accumulate item by item. For example, if there are only kitchens and toilets, it will be 2 points.
F4: Of the five questions in this item, "very convenient" is 1, "convenient" is 0.5, and "inconvenient" is 0. The five questions are scored together, with a maximum of 5 points. If the lowest total score is 0 ~ 1, it is 1.
F6: There are four questions in this item, with 0. 1.2 points for each question in turn. The scores of the four questions are added together, with the highest score of 8 and the lowest total score of 0. 1, average score 1. Then (total score ÷8×5) is converted into 1 ~ 5 points.
F8: 1:≥60% 2:50%-59.9% 3:40%-49.9% 4:20%。 39.9% 5 points:
F5 1, F52, F56, F55: All four items are five questions.
The scoring method for each project is the same. The highest score of an item is 6, and the lowest score is O, and then the final score is 0-5 according to the score of this item ÷6×5. If it is 0. If the score is 1, it is 1.
F60: entertainment type:
6 kinds of rice 5 points, 4 ~ 5 kinds of rice 4 points, 2 ~ 3 kinds of rice 3 points 1 seed rice 2 points none 1 minute.
Entertainment time:
& gt28 hours, 22-27 hours and 5 minutes per week, 4 minutes per week 15.2 1 hour, 8- 14 hours and 3 minutes per week, 0-7 hours and 2 minutes per week 1 hour.
When the two items are added and divided by 2, the score result is 1 ~ 5 points.
F69: 1 point 50%
2. Factor scoring method
There are 20 factors in GI ~ LI-74 * *, and each factor reflects a certain aspect of the quality of life of the subjects. Among them, 1 ~ 19 factor belongs to four dimensions (see below), and the 20th factor is the overall evaluation of the quality of life of the subjects. Factor scores are added or weighted according to items, with the maximum score of 20 and the minimum score of 4 for each factor. In order to draw intuitively, the scores of each factor are converted into the range of 0 ~ 100 with the following formula.
Factor conversion score = (factor rough score14) ×10016.
Factor 1: housing
The housing area, conditions and subjective satisfaction of the subjects were measured. Including F 1, F2, F3 * * *.
The scoring method is F 1+F2+F3×2.
Factor 2: Community service
Measure the evaluation and subjective satisfaction of the subjects on the living community environment, including F4 and F5 * * *.
The scoring method is F4×2+F5×2.
Factor 3: living environment
The natural environment and subjective satisfaction of subjects were measured, including F6 and F7 * * *.
The scoring method is F6×2+F7×2.
Factor 4: Economic situation
The economic income, expenses, medical expenses and subjective satisfaction of the subjects were measured. Including F8, F9 and FIO * * *.
The scoring method is F8×1.4+F9× 0.6+F10× 2.
Factor 5: Sleep and energy
Measurement: ① the satisfaction of energy state when the subjects are engaged in daily work or activities in daily life (such as entertainment); ② The sleep quality and satisfaction of the subjects have nothing to do with the causes of sleep disorders. Including f11-f15 * * * 5.
The scoring method is (f11+f12)/2+f13+f14+f15.
Factor 6: Physical discomfort
Determine whether the subject feels unwell or painful and its degree; Or the degree of dependence on a drug due to physical problems and diseases; And satisfaction with physical health. Including F 16 ~ 19 * * * 4.
The scoring method is (f16+17+18)/1.5+f19× 2.
Factor 7: Feeding function
To determine whether the subjects' appetite and food intake are normal and their satisfaction with the dietary status. Include F20, F2 1 and F22***3.
The scoring method is F20+F2 1+F22×2.
Factor 8: sexual function
Sexual frequency, sexual function and subjective satisfaction were measured. Including F23, F24 and F25***3.
The scoring method is F23+F24+F25×2.
Factor 9: Motor and sensory functions
Measure the basic ability and role function of daily life. Including vision, hearing, self-care ability, daily life transaction processing ability and subjective satisfaction. Including F26 ~ F30 * * * 5.
The scoring methods are F26+(F27+F28) and 2+F29+F30.
Factor 10: mental stress
Determine the amount of stressful life events, the degree of mental tension, whether there is dependence on certain substances to relieve psychological pressure or troubles, and subjective satisfaction. Including F3 1, F32, F33, F50***4.
The scoring method is (1+f32+f50)/1.5+f33× 2.
Factor 1 1: negative emotions
Measure the negative emotions of the subjects, including depression, anxiety, irritability or emotional dullness. From F34 to F37 * * 4.
The scoring method is f34. +f35+f36+f37。
Factor 12: positive emotions
Measure the positive emotions of the subjects, such as whether they are full of hope for life and whether they experience the happiness and degree of life. Including F38, F39 and F40***3.
Scoring method: F38+F39+F40×2.
Factor 13: cognitive function
The thinking ability, attention, memory, decision-making ability and subjective satisfaction were measured. Including F4 1 ~ F45 * * * 5.
The scoring method is (F4 1+). F42+F43+.F44)/2+F45×2
Factor 14: self-esteem
Measure the self-confidence and self-esteem of the subjects. Including F46 ~ F49 * * * 4.
The scoring method is f46+f47+.f48+ 1749.
Factor 15: social support
This factor not only reflects the social support of the subjects, but also reflects their ability to help others and subjective satisfaction. Including F5 1~F54***4.
The scoring method is F51+1752+:f53+f54.
Factor 16: interpersonal skills
The interpersonal relationship and subjective satisfaction with family, friends, colleagues and leaders were measured. Including F55 1757***3.
The scoring method is F55~+F56+F57×2.
Factor 17: work and study.
Measure work ability, work efficiency, ability to learn or pay attention to information necessary to complete professional roles, and subjective satisfaction. Including F58, F59, 1763, F64, F65 * * 5.
The scoring methods are (F55+F59)/2+(F63+F64), 2+F65×2.
Factor 18: amateur entertainment life
The types of entertainment, time and satisfaction with amateur entertainment were measured. Including F60-F62***3.
The scoring method is F60+F6 1+F62×2.
Factor 19: marriage and family
Intimacy, communication style, the amount of housework undertaken and satisfaction with marriage and family were all measured. Including F66 ~ F70 * * * 5.
The scoring method is (F66+1767)/2+:F68+F69+F70.
Factor 20: Overall evaluation of quality of life
The overall evaluation and subjective satisfaction of the subjects on health and quality of life were measured. Including G 1 ~ G4 * * * 4.
The scoring method is Gl+G2+G3+G4.
3. Dimension score
GQOL-74 includes four dimensions: physical function, psychological function, social function and material life, and each dimension includes the following factors:
The dimension of physical function includes five factors: sleep and energy, physical discomfort, eating function, sexual function, exercise and sensory function.
The dimensions of psychological function include factors 10 ~ 14, namely, mental tension, negative emotions, positive emotions, cognitive function and self-esteem.
Social function dimensions include factors 15 ~ 19, namely social support, interpersonal skills, work and study, amateur entertainment, marriage and family.
The dimension of material life includes four factors: housing, community service, living environment and economic situation. The scoring methods of physical function, psychological function and social function are roughly divided into five factors in each dimension, and the scoring range is 20 ~ 100. Convert to 0- 100 points according to the following formula.
(The dimension is roughly divided into 20)× 100÷80
The dimension of material life is roughly divided into four factors, and the score range is 16 ~ 80. Convert to 0 ~ 100 points according to the following formula.
(rough size-16)× 100÷64
4. Total score
The rough addition of 20 factors is equal to the total rough score. The score range is 80~400 points, which can be converted into 0 ~ 100 points according to the following formula: (the dimension is roughly divided into 80)× 100÷32)