Wisconsin Family Quality of Life Index (F-QLI)
Family Quality of Life Index (F-QLI)
Marion A. Becker‚ Bret R. Shaw‚ Lisa M. Reib (1996)
پرسشنامه کیفیت زندگی خانواده
The Family Quality of Life Index
این ابزار کامل نیست، لطفا منبع را ببینید.
It’s not complete instrument: please see source.
BACKGROUND INFORMATION
Date of birth‚ Sex‚ highest school grade‚ current relationship/marital status‚ First names of members residing in household‚ source of family’s income‚ racial/ethnic background‚ lived with …‚ lived primarily at …‚ How adequate is your housing? (Check one)
SATISFACTION LEVEL
Now we would like to ask you some questions about your satisfaction with aspects of your family life.
Very dissatisfied‚ Moderately dissatisfied‚ A little dissatisfied‚ Neither satisfied nor dissatisfied‚ A little satisfied‚ Moderately satisfied‚ Very satisfied
· How satisfied or dissatisfied are you with the way you and your family spend time together?
· How satisfied or dissatisfied are you with the activities you do with your family?
· How satisfied or dissatisfied are you with the meals your family shares? Don’t eat together
· How satisfied or dissatisfied are you with the food your family eats?
· How satisfied or dissatisfied are you when you are alone?
· How satisfied or dissatisfied are you with your family’s housing?
· How satisfied or dissatisfied are you with your neighborhood as a place for your family to live in?
· How satisfied or dissatisfied are you with the safety of your neighborhood?
· How satisfied or dissatisfied are you with your personal safety?
· How satisfied or dissatisfied are you with the clothing your family wears?
· How satisfied or dissatisfied are you with routines (i.e. time for bed‚ meals‚ school‚ work) in your family? No routines
· How satisfied or dissatisfied are you with the services your family uses?
· How satisfied or dissatisfied are you with your family’s access to transportation?
· How satisfied or dissatisfied are you with your sex life? Does not apply
We have asked how satisfied you are with different parts of your family life. Now we would like to know how important each of these aspects of your family life are.
Not at all important‚ Slightly important‚ Moderately important‚ Very important‚ Extremely important
· How important to you is the way your family time is spent?
· How important to you are the activities you do with your family?
· How important is sharing meals with your family?
· How important to you is the food your family eats?
· How important is it to feel comfortable when alone?
· How important is your family’s housing?
· How important is your neighborhood as a place for your family to live in?
· How important is your neighborhood safety?
· How important is your personal safety?
· How important to you is the clothing your family wears?
· How important to you is it that your family have routines (i.e. time for bed‚ meals‚ school‚ work)?
· How important to you are the services your family uses?
· How important to you is your family’s access to transportation?
· How important to you is your sex life?
ACTIVITIES AND OCCUPATIONS
· In the past four weeks‚ would you say that your family life has been: Poor‚ Fair‚ Good‚ Very Good‚ Excellent
· During the past four weeks‚ you have: (Check one)
· About how many hours a week do you work or go to school? Hours per week = ….
· What is your occupation?
· Do you work:? inside the home outside the home
Below are activities that you may have participated in recently. Please check YES or NO to indicate whether you have done the activity in the past four weeks.
· Gone for a walk
· Gone to a social group
· Gone to a movie or play
· Read a magazine or newspaper
· Watched TV
· Gone to church‚ synagogue‚ mosque
· Played cards
· Listened to a radio
· Played a sport
· Gone to a library
· How do you and your family spend time together? Please list the most frequent activities below.
1. … ………
2. … …….
3. … …….
We spend no time together
· Do you feel that you are engaged in family activities: (Choose one): Less than you would like‚ More than you would like‚ As much as you want
· How many meals in a week does your family eat together?
· Overall‚ I feel close to my family. Not at all‚ A little bit‚ Somewhat‚ Quite a bit‚ Very much
HEALTH AND WELL-BEING
Now we would like to know how you feel about things in your life. For each of the following questions‚ check the boxes that best describe how you have felt in the past four weeks. YES‚ NO
· Pleased about having accomplished something?
· Very lonely or remote from other people?
· Bored?
· That things went your way?
· So restless that you couldn't sit long in a chair?
· Proud because someone complimented you on something you had done?
· Upset because someone criticized you?
· Particularly excited or interested in something?
· Depressed or very unhappy?
· On top of the world?
· In general‚ I am able to accomplish the things that I need to do. Strongly agree ‚Agree‚ Disagree‚ Strongly disagree
· In general‚ I am able to cope with conflict and stress. All of the time‚ Most of the time‚ A good bit of the time‚ Some of the time‚ A little of the time‚ None of the time
· In the past four weeks you would best describe your physical health as: Poor‚ Fair‚ Good‚ Very Good‚ Excellent
· How do you feel about your physical health? (Check one)
· How important to you is your physical health? (Check one)
· Have you been prescribed medications? Yes No
If yes‚ please list all medications:
· Do you take these medications as prescribed? Yes No
· If you take medications for behavioral or mood problems‚ do you feel the medication helps? Not at all‚ Some‚ A fair amount‚ Quite a bit‚ Eliminates all symptoms
ALCOHOL & OTHER DRUGS
· Over the past four weeks have you drank any alcohol? Yes‚ No
· If yes‚ (number of days) on how many days have you had any alcohol to drink? ...
· On the days you drank‚ what was the average amount you consumed? (number of drinks per day)
· Over the past four weeks have you used any street drugs (cocaine‚ marijuana‚ heroin‚ speed‚ LSD‚ etc.)? Yes‚ No
· If yes‚ on how many days have you used any street drugs? (number of days)
· Over the past four weeks have you used tobacco? Yes‚ No
· If yes‚ on how many days have you used tobacco? (number of days)
SUBSTANCE USE
· Now that we have asked you about your substance use please tell us about its effects on your life. Please check all the answers that apply and most closely reflect your situation.
No use‚ Use; but no problem‚ Use; but it helps me‚ Moderate problem‚ Severe problem‚ Extremely severe problem
Alcohol
Tobacco
Marijuana
Other Street Drugs
Prescription Drugs
Over the Counter
Caffeine
· Has anyone ever spoken to you about your substance use? Yes‚ No
· If yes‚ did they consider your use as a problem? Yes‚ No
SOCIAL RELATIONS / SUPPORT
Very dissatisfied‚ Moderately dissatisfied‚ A little dissatisfied‚ Neither satisfied nor dissatisfied‚ A little satisfied‚ Moderately satisfied‚ Very satisfied
· How satisfied or dissatisfied are you with the number of friends your family has? No friends
· How satisfied or dissatisfied are you with how you and your family get along with friends?
· How satisfied or dissatisfied are you with your relationship with your children? No children
· How satisfied or dissatisfied are you with your relationship with your spouse/partner? No spouse/partner
· How satisfied or dissatisfied are you with the way your family communicates with each other?
· How satisfied or dissatisfied are you with how your family expresses caring for one another?
· How satisfied or dissatisfied are you with how you get along with people outside of your family?
· How satisfied or dissatisfied are you with the way your family resolves problems?
· How many people outside of your family do you count as your friends? None‚ 1-2‚ 3-5‚ over 5
IMPORTANCE LEVEL
Not at all important‚ Slightly important‚ Moderately important‚ Very important‚ Extremely important
· How important is it to have friends outside of the family?
· How important is it to get along with friends?
· How important is your relationship with your child/children?
· How important is your relationship with your spouse?
· How important is family communication?
· How important is the expression of caring within the family?
· How important is it for family members to get along?
· How important to you is the way your family resolves problems?
During the past four weeks you have (check one): …
GOAL ATTAINMENT
· Goal 1: ______________________________________
How important is this goal to you? Please check the box below to indicate how important this goal is to you. Not at all important 1 2 3 4 5 6 7 8 9 10 Extremely Important
To what extent have you achieved this goal? Please check the box below to indicate the extent to which you have achieved this goal. Not at all achieved 1 2 3 4 5 6 7 8 9 10 Completely achieved
· Goal 2: ______________________________________
How important is this goal to you? Please check the box below to indicate how important this goal is to you. Not at all important 1 2 3 4 5 6 7 8 9 10 Extremely Important
To what extent have you achieved this goal? Please check the box below to indicate the extent to which you have achieved this goal. Not at all achieved 1 2 3 4 5 6 7 8 9 10 Completely achieved
· Goal 3: ______________________________________
How important is this goal to you? Please check the box below to indicate how important this goal is to you. Not at all important 1 2 3 4 5 6 7 8 9 10 Extremely Important
To what extent have you achieved this goal? Please check the box below to indicate the extent to which you have achieved this goal. Not at all achieved 1 2 3 4 5 6 7 8 9 10 Completely achieved
been having good relationships with others and receiving support from family and friends
· been receiving only moderate support from family and friends
· had infrequent support from family and friends or only when absolutely necessary
Please check the box below to indicate how you feel about your family’s quality of life during the past four weeks. Lowest quality means things are as bad as they could be. Highest quality means things are the best they could be.
· LOWEST QUALITY 1 2 3 4 5 6 7 8 9 10 HIGHEST QUALITY
· If your family’s quality of life is less than you hope for‚ how hopeful are you that you will eventually achieve your desired quality of life? (Check one): Not at all‚ Somewhat‚ Moderately‚ Very
· How much control do you feel you have over the important areas of your family life? (Check one): None‚ Some‚ A moderate amount‚ A great amount
· Has a child from your family ever been placed outside the home? Yes‚ No‚ If yes; for how long?
· Have you ever believed that your family would be better off if a child was placed outside the home? Yes‚ No
· Do you think that it is possible that a child may be placed out of the home in the future? Yes‚ No
How important are each of the following factors in determining your family’s quality of life?
Not at all important‚ Slightly important‚ Moderately important‚ Very important‚ Extremely important
· Family activities
· Your feelings about the family
· Your physical health
· Friends‚ people you spend time with outside of the family
· Ability to take care of yourself and your family
· Your emotional health
· Other‚ please specify:
شرح سایت روان سنجی: ابزارکیفیت زندگی ویسکانسین مورد بهره برداری پژوهشگران، دانشگاهیان و کارخانه های دارویی. در بهداشت روانی است و بیشتر بر اختلال شیزوفرنی تکیه دارد.
این ابزار دارای نسخه های مراجع، ارائه دهنده خدمات، مراقب (مددکار) و خانواده است.
پرسشنامه خانواده، به زمینه های: خشنودی از زندگی، فعالیت های روزمره ، سلامتی فیزیکی، بهداشت روانی، روابط اجتماعی، سوء مصرف مواد ، دستیابی به اهداف و مواردی چون : امید و کانون مهار می پردازد.
1) life satisfaction‚ 2) activities of daily living‚ 3) physical health‚ 4) psychological well-being‚ 5) social relations‚ 6) alcohol and other drug abuse‚ and 7) goal attainment
چگونگی دستیابی
If you have any questions about this questionnaire‚ please call or write Marion Becker‚ Ph.D.‚ University of South Florida‚ Department of Community Mental Health‚ 13301 Bruce B. Downs Blvd.‚ MHC 1423‚ Tampa‚ Florida 33612-3899 Telephone: (813)974-7188 Fax: (813)974-6469 E-Mail: .becker@fmhi.usf.edu