Care Coordination Program
Quality of life self-assessment
First name Last name
Address City/Town Zip code
Care Coordinators name TEST TEST2 TEST3 Today's date Birth date (ex.12/12/1975)
Please rate the following: 0 = Poor 1 = Fair 2 = Good 3 = Excellent
1. The place where you are living (your housing) 0 1 2 3
Comment
2. The amount of money that you have to buy what you need 0 1 2 3
3. Your involvement in work, employment 0 1 2 3
4. Your level of education 0 1 2 3
5. Your access to transportation to get around 0 1 2 3
6. Your social life 0 1 2 3
7. Your participation in community activities (i.e. leisure, sports, spiritual, volunteer work) 0 1 2 3
8. Your ability to have fun and relax 0 1 2 3
9. Your physical health 0 1 2 3
10. Your level of independence 0 1 2 3
11. Your ability to take care of yourself ( staying healthy, eating right, avoiding danger) 0 1 2 3
12. Your self-esteem (how you feel about yourself) 0 1 2 3
13. The effect of alcohol & drugs in your life 0 1 2 3
14. Your mental health symptoms 0 1 2 3
15. Overall how are things going in your life? 0 1 2 3