It is hard for you to walk: 0 – Not at all 2 – Sometimes 4 – A lot Unknown or Not Documented It is hard for you to run: 0 – Not at all 2 – Sometimes 4 – A lot Unknown or Not Documented It is hard for you to play sports or exercise: 0 – Not at all 2 – Sometimes 4 – A lot Unknown or Not Documented It is hard for you to pick up big things: 0 – Not at all 2 – Sometimes 4 – A lot Unknown or Not Documented It is hard for you to take a bath or shower: 0 – Not at all 2 – Sometimes 4 – A lot Unknown or Not Documented It is hard for you to do chores (like pick up your toys): 0 – Not at all 2 – Sometimes 4 – A lot Unknown or Not Documented Do you have or aches: 0 – Not at all 2 – Sometimes 4 – A lot Unknown or Not Documented If yes, where? __________ Do you ever feel too tired to play: 0 – Not at all 2 – Sometimes 4 – A lot Unknown or Not Documented EMOTIONAL FUNCTIONING (problems with…) Do you feel scared: 0 – Not at all 2 – Sometimes 4 – A lot Unknown or Not Documented
SCHOOL FUNCTIONING (problems with…) Is it hard for you to pay attention in school: 0 – Not at all 2 – Sometimes 4 – A lot Unknown or Not Documented Do you forget things: 0 – Not at all 2 – Sometimes 4 – A lot Unknown or Not Documented Is it hard to keep up with schoolwork: 0 – Not at all 2 – Sometimes 4 – A lot Unknown or Not Documented Do you miss school because of not feeling good: 0 – Not at all 2 – Sometimes 4 – A lot Unknown or Not Documented Do you miss school because you have to go to the doctor or hospital: 0 – Not at all 2 – Sometimes 4 – A lot Unknown or Not Documented PedsQL Child (Child 8-12 yrs) MY HEALTH AND ACTIVITIES (problems with…) It is hard for me to walk more than one block: 0 – Not at all 1 – Almost Never 2 – Sometimes 3 – Often 4 – A lot Unknown or Not Documented It is hard for me to run: 0 – Not at all 1 – Almost Never 2 – Sometimes 3 – Often 4 – A lot Unknown or Not Documented It is hard for me to do sports or exercise: 0 – Not at all
I cannot do things kids my age can do: 0 – Not at all 1 – Almost Never 2 – Sometimes 3 – Often 4 – A lot Unknown or Not Documented It is hard to keep up when I play with kids: 0 – Not at all 1 – Almost Never 2 – Sometimes 3 – 4 – A lot Unknown or Not Documented ABOUT SCHOOL (problems with…) Is it hard to pay attention in school: 0 – Not at all 1 – Almost 2 – Sometimes 3 – Often 4 – A lot Unknown or Not Documented I forget things: 0 – Not at all 1 – Almost Never 2 – Sometimes 3 – Often 4 – A lot Unknown or Not Documented I have trouble keeping up with schoolwork: 0 – Not at all 1 – Almost Never 2 – Sometimes 3 – Often 4 – A lot Unknown or Not Documented I miss school because of not feeling well: 0 – Not at all 1 – Almost Never 2 – Sometimes 3 – Often 4 – A lot Unknown or Not Documented I miss school to go to the doctor or hospital: 0 – Not at all 1 – Almost Never 2 – Sometimes 3 – Often
4 – A lot Unknown or Not Documented PedsQL Child (Teen 13-18 yrs) ABOUT MY HEALTH AND ACTIVITIES (problems with…) It is hard for me to walk more than one block: 0 – Not at all 1 – Almost Never 2 – Sometimes 3 – Often 4 – A lot Unknown or Not Documented It is hard for me to run: 0 – Not at all 1 – Almost Never 2 – Sometimes 3 – Often 4 – A lot Unknown or Not Documented It is hard for me to do sports or exercise: 0 – Not at all 1 – Almost Never 2 – Sometimes 3 – Often 4 – A lot Unknown or Not Documented It is hard for me to lift something heavy: 0 – Not at all 1 – Almost Never 2 – Sometimes 3 – Often 4 – A lot Unknown or Not Documented It is hard for me to take a bath or shower by myself: 0 – Not at all 1 – Almost Never 2 – Sometimes 3 – Often 4 – A lot Unknown or Not Documented It is hard for me to do chores around the 0 – Not at all 1 – Almost Never 2 – Sometimes 3 – Often 4 – A lot Unknown or Not Documented I hurt or ache: 0 – Not at all
1 – Almost Never 2 – Sometimes 3 – Often 4 – A lot Unknown or Not Documented If yes, where? __________ I have low energy : 0 – Not at all 1 – Almost Never 2 – Sometimes 3 – 4 – A lot Unknown or Not Documented ABOUT MY FEELINGS (problems with…) I feel afraid or scared: 0 – Not at all 1 – Almost Never 2 – Sometimes 3 – Often 4 – A lot Unknown or Not Documented I feel sad or blue: 0 – Not at all 1 – Almost 2 – Sometimes 3 – Often 4 – A lot Unknown or Not Documented I feel angry: 0 – Not at all 1 – Almost Never 2 – Sometimes 3 – Often 4 – A lot Unknown or Not Documented I have trouble sleeping: 0 – Not at all 1 – Almost Never 2 – Sometimes 3 – 4 – A lot Unknown or Not Documented I worry about what will happen to me: 0 – Not at all 1 – Almost Never 2 – Sometimes 3 – Often 4 – A lot Unknown or Not Documented
4 – Almost Always Unknown or Not Documented EMOTIONAL FUNCTIONING (problems with…) Feeling afraid or scared: 0 – Never 1 – Almost 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented Feeling sad or blue: 0 – Never 1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented Feeling angry: 0 – Never 1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented Trouble sleeping: 0 – 1 – Almost 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented Worrying: 0 – Never 1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented SOCIAL FUNCTIONING (problems with…) Playing with other children: 0 – Never 1 – Almost 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented Other kids not wanting to play with him or her: 0 – Never
1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented Getting teased by other children: 0 – Never 1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented Not able to do things that children his or her age can do: 0 – Never 1 – Almost Never 2 – Sometimes 3 – 4 – Almost Always Unknown or Not Documented Keeping up when playing with other children: 0 – Never 1 – Almost 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented SCHOOL FUNCTIONING (problems with…) Doing the same school activities as peers: 0 – Never 1 – Almost Never 2 – Sometimes 3 – 4 – Almost Always Unknown or Not Documented Missing school/daycare because of not feeling well: 0 – 1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented Missing school/daycare to go to the doctor or hospital: 0 – Never 1 – Almost 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented
PedsQL Parent (Young Child 5-7 yrs) PHYSICAL FUNCTIONING (problems with…) Walking more than one blcok: 0 – Never 1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented Running: 0 – Never 1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented Participating in sports activity or exercise: 0 – Never 1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented Lifting something heavy: 0 – Never 1 – Almost 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented Taking a bath or shower by him or herself 0 – 1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented chores around the house: 0 – Never 1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented Having hurts or aches: 0 – Never 1 – Almost Never
2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented Low energy 0 – 1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented EMOTIONAL FUNCTIONING (problems with…) Feeling afraid or scared: 0 – Never 1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented Feeling sad or blue: 0 – 1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented Feeling angry: 0 – Never 1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented Trouble sleeping: 0 – Never 1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented Worrying about what will happen to him or her: 0 – Never 1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented SOCIAL FUNCTIONING (problems with…)
Unknown or Not Documented Keeping up with activities: 0 – Never 1 – Almost 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented Missing school because of not feeling well: 0 – 1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented Missing school to go to the doctor or hospital: 0 – Never 1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented PedsQL Parent (Child 8-12 yrs) PHYSICAL FUNCTIONING (problems with…) Walking more than one blcok: 0 – Never 1 – Almost 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented Running: 0 – Never 1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented Participating in sports activity or exercise: 0 – 1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented Lifting something heavy:
0 – Never 1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented Taking a bath or shower by him or herself 0 – Never 1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented Doing chores around the house: 0 – Never 1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented Having hurts or aches: 0 – Never 1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented Low energy level: 0 – Never 1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented EMOTIONAL FUNCTIONING (problems with…) Feeling afraid or scared: 0 – Never 1 – Almost 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented Feeling sad or blue: 0 – Never 1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented
Feeling angry: 0 – Never 1 – Almost 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented Trouble sleeping: 0 – 1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented Worrying about what will happen to him or her: 0 – Never 1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented SOCIAL FUNCTIONING (problems with…) Getting along with other children: 0 – Never 1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented Other children not wanting to be his or her friend: 0 – Never 1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented Getting teased by other children: 0 – Never 1 – Almost Never 2 – Sometimes 3 – 4 – Almost Always Unknown or Not Documented Not able to do things that other children his or her age can do: 0 – 1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented
Keeping up when playing with other children: 0 – Never 1 – Almost 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented SCHOOL FUNCTIONING (problems with…) Paying attention in 0 – Never 1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented Forgetting things: 0 – Never 1 – Almost Never 2 – Sometimes 3 – 4 – Almost Always Unknown or Not Documented Keeping up with activities: 0 – Never 1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented Missing school because of not feeling well: 0 – Never 1 – Almost 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented Missing school to go to the doctor or hospital: 0 – Never 1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented PedsQL Parent (Teen 13-18 yrs) PHYSICAL FUNCTIONING (problems with…) Walking more than one blcok: 0 – Never
2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented EMOTIONAL FUNCTIONING (problems with…) Feeling afraid or scared: 0 – Never 1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented Feeling sad or blue: 0 – 1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented Feeling angry: 0 – 1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented Trouble sleeping: 0 – Never 1 – Almost 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented Worrying about what will happen to him or her: 0 – Never 1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented SOCIAL FUNCTIONING (problems with…) Getting along with other teens: 0 – Never 1 – Almost Never 2 – Sometimes 3 – 4 – Almost Always Unknown or Not Documented
Other teens not wanting to be his or her friend: 0 – Never 1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented Getting teased by teens: 0 – Never 1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented Not able to do things that other teens his or her age can do: 0 – Never 1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented Keeping up with other teens: 0 – 1 – Almost 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented SCHOOL FUNCTIONING (problems with…) Paying attention in class: 0 – 1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented Forgetting things: 0 – Never 1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented Keeping up with school schoolwork: 0 – Never 1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always