Patient Weighted Quality Of Life In Epilepsy: QOLIE-10-P 2OLE-02 CA rere cnr tte COLE Decent Goan A eet [Today's Date: T 7 Your Name. w Your Age:__ years, INSTRUCTIONS ‘The QOLIE-10-P is 2 bret survey of health-related quaity of ie for aduts with eniepsy. There are 10 questions about health and daily actvites, one question about how much distess you fee! about problems and worres tolled lo epilepsy. and a review of what bothers you most. This quesbonnaite should be comaleled only by the person who has epilepsy (nol a relative or frend) because no ore else knows how VOU foal Answer every question by Circing the appropriate number (1,2. 9_). lf you are unsure about how to answer a question, please give the best answer you can and wrile 2 comment or explanation on the side ofthe page. ‘These notes may be useful # you dacuss the GOLIE-10 with your doctor. Completing the GOLIE-1G-2 belore ang atter teatment and your Goctos undersians Fou the cuanges have affectes your ie. ‘These questions are about how you have been FEELING and the types af problems you have been traving uring the past 4 weeks. Far each question, please give the one answer that comes closest lo the way you have been feeling. ‘How much ofthe time during the past € weeks. {Gre one number on each tne) dee Se “Ene Sos Se ae eos se SS 1. Did youhave alot ol energy? {oF 2 4 ww 2. Have you tot dawnhearted and low? 4 2 4 4 #© & 3. How much ofthe time ducing the past 4 weeks your epiensy orantoplepic drugs have caused trouble with driving (or other transportation) Ages At Sere onsite sete! i 2) 4 ws During the past 4 weeks... share Sone 4. How much do your work limitations bother you? 1 a 4 4 5 5. How much do your social limitations bother you? ‘ 2 3 6 5 (2OLEIOD Ad vam sony hs QOL Den ae A haar PoetDuring the past 4 weeks... 6. How much co your memory difficulties bother you? 7. How much co physical effects of antenioptc drugsboter gg you? 8. How much do psychological effects of antienieptc ‘drugs bather you? 8. How afraid are you of having 2 seizure curing the neat 4 weeks? 10. How has your QUALITY OF LIFE boen during the past 4 weeks (thats, now have things been going for you)? (Circle one number ‘on the ladder) Pretty good. (Good & bad about equal ‘Very bad: T ‘could hardly have been Page‘Roviowing ai the questions you have answered above, consider the gyarallimpact of these probloms on your ‘quality of ie in the past # weeks. (Circe one number) etal Seeders) At Vent “11_How much does the state of your eplepsycolated + 2 ls (ally of ile distress you cveral?™ 12. Number the folowing topics rom ‘to 7 wih 1" coesponting othe most important topic and "tothe Jeast mpartant ene. Please uso 0ach number only once, Energy (edness) Emovons (mood) Daly actives (work, ving, socal & oter activites) Mental function (inking, concetrating, memory) Medication eects (physical, mental) ‘Worry about seizures (impacto sezires) Overal quality fife CEECCCL onmeoe >