Quality of Life Assessment
(Please Print and Complete Form)
Name:
DOB:
Acct#:
How is this affecting your quality of life?
What symptoms bring you into the office today?
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How long have you been experiencing these symptoms? _________________________________________
What methods have you tried to relieve your symptoms? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
What are you most concerned of regarding this condition? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
What health conditions are you afraid this might be connected or lead to:(circle all that apply)
Family history problems
Fibromyalgia
Heart Disease
Depression
Cancer
Chronic Fatigue
Diabetes
Necessary Surgery
Arthritis
Other: ____________________________________________
How has your health condition affected your job, relationships, finances, family, or other activities? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
What has this cost you? (time, money, sleep, relationships, job opportunities, etc) ________________________________________________________________________________________________________
Where do you picture yourself in 1-3 years if this problem does not get resolved: ______________
________________________________________________________________________________________________________________________________________________________________________________________________________________
How would life look different without this issue?
___________________________________________________
________________________________________________________________________
_______________________________
On a Scale of 1-10, How much do you value your health? _______________
What do you desire most in working with us? _____________________________________________________
What would that mean to you? ____________________________________________________________________