Member Outcome Survey

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Member Outcome Survey

Instructions: This assessment asks how you feel about your quality of life, health and other areas. Please answer all the questions. If you are unsure, choose the one that seems most appropriate for you.

Think about your life in the last 2 weeks. Please read each question, assess your feelings and choose the best answer for you.

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Date(Required)

How would you rate your quality of life?

How satisfied are you with your health?

To what extent do you feel that physical pain prevents you from doing what you need to do?

How much do you need any medical treatment to function in your daily life?

How much do you enjoy life?

To what extent do you feel your life to be meaningful?

How well are you able to concentrate?

How safe do you feel in your daily life?

How healthy is your physical environment?

Do you have enough energy for everyday life?

Are you able to accept your bodily appearance?

Have you enough money to meet your needs?

How available to you is the information that you need in your day-to-day life?

To what extent do you have the opportunity for leisure activities?

How well are you able to get around?

How satisfied are you with your sleep?

How satisfied are you with your ability to perform your daily living activities?

How satisfied are you with your capacity for work?

How satisfied are you with yourself?

How satisfied are you with your personal relationships?

How satisfied are you with your sex life?

How satisfied are you with the support you get from your friends?

How satisfied are you with the conditions of your living place?

How satisfied are you with your access to health services?

How satisfied are you with your transportation?

How often do you have negative feelings such as blue mood, despair, anxiety, depression?

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4245 Forest Park Ave. St. Louis, MO 63108 Phone: 314-533-4245 Email: info@independencecenter.org

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TTY Crisis Hotline for Hearing Impaired: First dial 711 and then 988. Or text 988.

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Member Outcome Survey