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REQOL Form
Your Initials
Therapist Name
Today's Date
MM slash DD slash YYYY
Please select
1 month
6 months
Final month
For each of the following statements, please check one box that best describes your thoughts, feelings, and activities over the past week.
1. I found it difficult to get started with everyday tasks.
*
None of the time
Only occasionally
Sometimes
Often
Most or all of the time
2. I felt able to trust others.
*
None of the time
Only occasionally
Sometimes
Often
Most or all of the time
3. I felt unable to cope.
*
None of the time
Only Occasionally
Sometimes
Often
Most or all of the time
4. I could do the things I wanted to do.
*
None of the time
Only occasionally
Sometimes
Often
Most or all the time
5. I felt happy.
*
None of the time
Only occasionally
Sometimes
Often
Most or all of the time
6. I thought my life was not worth living.
*
None of the time
Only occasionally
Sometimes
Often
Most or all the time
7. I enjoyed what I did.
*
None of the time
Only occasionally
Sometimes
Often
Most or all of the time
8. I felt hopeful about my future.
*
None of the time
Only occasionally
Sometimes
Often
Most or all of the time
9. I felt lonely.
*
None of the time
Only occasionally
Sometimes
Often
Most or all of the time
10. I felt confident in myself.
*
None of the time
Only occasionally
Sometimes
Often
Most or all of the time
11. I did things I found rewarding.
*
None of the time
Only occasionally
Sometimes
Often
Most or all of the time
12. I avoided things I needed to do.
*
None of the time
Only occasionally
Sometimes
Often
Most or all of the time
13. I felt irritated.
*
None of the time
Only occasionally
Sometimes
Often
Most or all of the time
14. I felt like a failure.
*
None of the time
Only occasionally
Sometimes
Often
Most or all of the time
15. I felt in control of my life.
*
None of the time
Only occasionally
Sometimes
Often
Most or all of the time
16. I felt terrified.
*
None of the time
Only occasionally
Sometimes
Often
Most or all of the time
17. I felt anxious.
*
None of the time
Only occasionally
Sometimes
Often
Most or all of the time
18. I had problems with my sleep.
*
None of the time
Only occasionally
Sometimes
Often
Most or all of the time
19. I felt calm.
*
None of the time
Only occasionally
Sometimes
Often
Most or all of the time
20. I found it hard concentrate.
*
None of the time
Only occasionally
Sometimes
Often
Most or all of the time
Please describe your physical health (problems with pain, mobility, difficulties caring for yourself or feeling physically unwell) over the past week.
*
No problems
Slight problems
Moderate problems
Severe problems
Very severe problems
Δ
