patient’s responses. Indicate on the instruments that the PedsQL and VADQoL were administered or administered verbally by another. There should be no coaching regarding responses. Enter the patient’s answers from the paper form into the database through . Data Screening The PedsQL and VADQoL are to be reviewed for missing or unclear data at the time of instrument completion. Corrections must be made with the patient at that time. Non Submission of PedsQL and VADQoL For patients who do not complete the PedsQL or VADQoL, please enter reason as to why the PedsQL or VADQoL were not completed as stated above. PedsQL Toddler 2-4yrs (Parent Report) PedsQL Young Child 5-7yrs (Child Report) PedsQL Young Child 5-7yrs (Parent Report) PedsQL 8-12yrs (Child Report) PedsQL Child 8-12yrs (Parent Report) PedsQL Teen 13-18yrs (Child Report) PedsQL Teen (Parent Report) VADQoL (> 8yrs) Report VADQoL (< 2yrs) Parent Report VADQoL (≥ 2yrs) Parent Report PedsQL: Child Did the child complete a form? Yes, No, or Unknown. Yes or No If no, please enter the reason the PedsQL form was not completed: Too Sick Administrative (check specific reason) Urgent implant, no time Coordinator too busy or forgot Unable to contact patient Other reason, specify _______ If yes, please select the ‘Child’ form: PedsQL Child (5-7yrs) PedsQL Child (8-12 yrs) PedsQL Teen (13-18 yrs)
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 Do you feel sad: 0 – Not at all 2 – Sometimes 4 – A lot Unknown or Not Documented Do you feel mad: 0 – Not at all 2 – Sometimes 4 – A lot Unknown or Not Documented Do you have trouble sleeping: 0 – Not at all 2 – Sometimes 4 – A lot Unknown or Not Documented Do you worry about what will happen to you: 0 – Not at all 2 – Sometimes 4 – A lot Unknown or Not Documented SOCIAL FUNCTIONING (problems with…) Is it hard for you to get along with other kids: 0 – Not at all 2 – Sometimes 4 – A lot Unknown or Not Documented Do other kids say they do not want to play with you: 0 – Not at all 2 – Sometimes 4 – A lot Unknown or Not Documented Do other kids tease you: 0 – Not at all 2 – Sometimes 4 – A lot Unknown or Not Documented
Unknown or Not Documented ABOUT MY FEELINGS (problems with…) I feel afraid or scared: 0 – Not at all 1 – Almost 2 – Sometimes 3 – Often 4 – A lot Unknown or Not Documented I feel sad or blue: 0 – Not at all 1 – Almost Never 2 – Sometimes 3 – Often 4 – A lot Unknown or Not Documented I feel angry: 0 – Not at all 1 – Almost 2 – Sometimes 3 – Often 4 – A lot Unknown or Not Documented I have trouble sleeping: 0 – Not at all 1 – Almost 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 HOW I GET ALONG WITH OTHERS (problems with…) I have trouble getting along with other kids: 0 – Not at all 1 – Almost 2 – Sometimes 3 – Often 4 – A lot Unknown or Not Documented kids do not want to be my friend: 0 – Not at all 1 – Almost Never
2 – Sometimes 3 – Often 4 – A lot Unknown or Not Documented Other kids tease me: 0 – Not at all 1 – Almost Never 2 – Sometimes 3 – Often 4 – A lot Unknown or Not Documented I cannot do things other kids my age can do: 0 – Not at all 1 – Almost 2 – Sometimes 3 – 4 – A lot Unknown or Not Documented It is hard to keep up when I play with other kids: 0 – Not at all 1 – Almost Never 2 – Sometimes 3 – Often 4 – A lot Unknown or Not Documented SCHOOL (problems with…) Is it hard to pay attention in school: 0 – Not at all 1 – Almost Never 2 – Sometimes 3 – Often 4 – A lot Unknown or Not Documented I forget things: 0 – Not at all 1 – Almost 2 – Sometimes 3 – 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
3 – Often 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 HOW I GET ALONG WITH OTHERS (problems with…) I have trouble getting along with other teens: 0 – Not at all 1 – Almost Never 2 – Sometimes 3 – Often 4 – A lot Unknown or Not Documented Other teens do not want to be my friend: 0 – Not at all 1 – Almost Never 2 – Sometimes 3 – 4 – A lot Unknown or Not Documented Other teens tease me: 0 – Not at all 1 – Almost Never 2 – Sometimes 3 – 4 – A lot Unknown or Not Documented I cannot do things other teens my age can do: 0 – Not at all 1 – Almost 2 – Sometimes 3 – Often 4 – A lot Unknown or Not Documented It is hard to keep up with peers: 0 – Not at all 1 – Almost Never 2 – Sometimes 3 – Often 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 Never 2 – Sometimes 3 – 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 – 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 – 4 – A lot Unknown or Not Documented I miss school to go to the doctor or hospital: 0 – Not at all 1 – Almost 2 – Sometimes 3 – 4 – A lot Unknown or Not Documented PedsQL: Parent Did the parent complete a form? Yes, No, or Unknown. Yes or No If no, please enter the reason the PedsQL form was not completed: Too Sick Administrative (check specific reason) Urgent implant, no time Coordinator too busy or forgot Unable to contact parent Other reason, specify _______ If yes, please select the ‘Parent’ form: PedsQL Toddler (2-4yrs) PedsQL Young Child (5-7yrs)
PedsQL Child (8-12 yrs) PedsQL Teen (13-18 yrs) PedsQL Parent (Toddler 2-4 yrs) PHYSICAL FUNCTIONING (problems with…) Walking: 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 active play or exercise: 0 – Never 1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented Lifting something 0 – Never 1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented Bathing: 0 – Never 1 – Almost Never 2 – Sometimes 3 – 4 – Almost Always Unknown or Not Documented Helping to pick up his or her toys: 0 – 1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented
Having hurts or aches: 0 – 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 2 – Sometimes 3 – 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: 0 – Never 1 – Almost 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented
SOCIAL FUNCTIONING (problems with…) Playing with other children: 0 – 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 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented Not able to do things that other children his or her age can do: 0 – Never 1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented Keeping up when playing with other children: 0 – 1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented SCHOOL FUNCTIONING (problems with…) the same school activities as peers: 0 – Never 1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented Missing school/daycare because of not feeling well: 0 – Never 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 Never 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 Never 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 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 Never 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 0 – 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 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 2 – Sometimes 3 – 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 – 1 – Almost Never 2 – Sometimes 3 – 4 – Almost Always Unknown or Not Documented Not able to do things that 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 Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented SCHOOL FUNCTIONING (problems with…) Paying attention in class:
0 – Never 1 – Almost Never 2 – Sometimes 3 – 4 – Almost Always Unknown or Not Documented Forgetting things: 0 – 1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented Keeping up with activities: 0 – 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 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 – 4 – Almost Always Unknown or Not Documented PedsQL Parent (Child 8-12 yrs) PHYSICAL FUNCTIONING (problems with…) Walking more than one blcok: 0 – 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 Never 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 – 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 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 – 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 – 1 – Almost Never 2 – Sometimes 3 – 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 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 – 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 other children his or her age can do: 0 – Never 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 class: 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 – Often 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 Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented
Missing school to go to the doctor or hospital: 0 – 1 – Almost Never 2 – Sometimes 3 – 4 – Almost Always Unknown or Not Documented PedsQL Parent (Teen 13-18 yrs) PHYSICAL FUNCTIONING (problems with…) Walking more than one 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 – 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 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 – 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 or aches: 0 – Never 1 – Almost 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented Low energy level: 0 – Never 1 – Almost Never 2 – Sometimes 3 – 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 0 – Never 1 – Almost Never 2 – Sometimes 3 – 4 – Almost Always Unknown or Not Documented Trouble sleeping: 0 – Never 1 – Almost Never 2 – Sometimes 3 – 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 with other teens: 0 – 1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented Other teens not wanting to be his or her friend: 0 – Never 1 – Almost 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented Getting teased by teens: 0 – Never 1 – Almost 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 – 4 – Almost Always Unknown or Not Documented Keeping up with other teens: 0 – Never 1 – Almost 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented SCHOOL FUNCTIONING (problems with…) Paying attention in class: 0 – Never 1 – Almost Never 2 – Sometimes 3 – 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 Unknown or Not Documented Missing school because of not feeling well: 0 – Never 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 VADQoL: Child (for children > 8yrs of age) Did the child complete a form? Yes, No, or Unknown. Yes or No If no, please enter the reason the VADQoL form was not completed: Too Sick Administrative (check specific reason) Urgent implant, no time Coordinator too busy or forgot Unable to contact patient Other reason, specify __________ If yes, the VAD QOL (Child form opens – see attached form) VAD QOL The VAD noise bothers me when I am awake: Always Very Sometimes Rarely Never Comments