QUALITY OF LIFE PROFILE FOR ADULTS

Questionnaire
Name:
Age:
Date:

These are 54 items on the questionnaire – 6 for each of the 9 areas of life. Each of the 54 items is scored
according to :

Its importance to you:

1 – not very important (if this item has extremely limited or no impact on your daily activities and/or thoughts. This
score means that this area of life is almost no relevance to your life)
2 – a little important (if this item has, some, but only a small, impact on your daily activities and/or thoughts, or it is not
very relevant to your life)
3 – important (if this item is part of your daily life activities, but does not take particular importance)
4 – quite important (if this item is a strong , but not dominating, force in your life. It should be used when many of your
daily activities and thoughts are determined by this area)
5 – very important (if this item is dominant and driving force in your life. This score means that this area of life is a
“reason for being”, and that it is highly important to your daily activities and/or thoughts)

Your leel of satisfaction with it:

1 – not very satisfied (if you are very dissatisfied with this area as of now)
2 – a little satisfied (if you are only little/mild satisfied with this area of life, as it is now)
3 – important (if you are satisfied with this area of life, but do not think about it especially)
4 – quite satisfied (if you are very satisfied – but not exceptionally so – with this area of life and it is a source of
considerable pleasure)
5 – very satisfied (if you are strongly satisfied with this area of life . you should feel extremely fulfilled in this area and
have strong feelings of pleasure or satisfaction that are of ongoing , not a temporary nature.

 Answer each question in terms of your life right as it is right now

 Answer each question whether or not you can actually participate in or do the activities described.
o For example, having a job may be very important to you even if you do not have one.

PHYSICAL BEING
Importance satisfaction
1 2 3 4 5 1 2 3 4 5
My appearance, how I look
My exercising and being fit
My hygiene – caring for myself
My nutrition and the food I eat
My physical health
My sex life

PSYCHOLOGICAL BEING
Importance satisfaction
1 2 3 4 5 1 2 3 4 5
Accepting the way I am
Being free of worry and stress
How I feel about myself
My mental health
The mood I’m usually in
Thinking and acting independently
SPIRITUAL BEING
Importance satisfaction
1 2 3 4 5 1 2 3 4 5
Celebrating special events of my life
Feeling that life has meaning
Having hope for the future
Having religious or spiritual beliefs
Helping others in need
My own ideas of right and wrong

PHYSICAL BELONGING
Importance satisfaction
1 2 3 4 5 1 2 3 4 5
Feeling safe were I live
Having a space for privacy
Having my own personal things
The house or apartment I live in
What neighborhood I live in
What part of the country I live in

SOCIAL BELONGING
Importance satisfaction
1 2 3 4 5 1 2 3 4 5
Being close to people in my family
Having a spouse or special person
Having friends
Speaking with acquaintances
Socializing within social groups
Thinking of myself as a part of a larger social group

COMMUNITY BELONGING
Importance satisfaction
1 2 3 4 5 1 2 3 4 5
Going to places in my community (stores, restaurant, etc)
Attending special events in our community (movies, fairs, etc)
Having access to education
Having access to meaningful work or activities
Having access to professional services (medical, social, etc)
Having my own money to spend

PRACTICAL BELONGING
Importance satisfaction
1 2 3 4 5 1 2 3 4 5
Doing work around my home
Helping other people to do things
Going places (errands ,appointments, etc)
Looking after myself
Looking after other people and pets
Working at a job, or attending schools
LEISURE BELONGING
Importance satisfaction
1 2 3 4 5 1 2 3 4 5
Attending public entertainment
Doing casual leisure activities (TY, reading, walks, etc)
Engaging in organized recreation activities
Having hobbies
Taking vacations and holidays
Visiting and socializing for enjoyment

GROWTH BELONGING
Importance satisfaction
1 2 3 4 5 1 2 3 4 5
Coping with changes in life
Improving my physical skills
Learning about new things
Resolving conflicts with others
Solving my problems
Trying out new things