RC - PedsQL Infant All - Eng USori

ID#
Date:
™
PedsQL
Pediatric Quality of Life Inventory
N
O
Infant Scales
SI
IS
PARENT REPORT for INFANTS (ages 1-12 months)
M
U PY
R
PE
O O
DIRECTIONS
H C
T
W IEW
On the following page is a list of things that might be a problem for your child.
Please tell us how much of a problem each one has been for your child
during the past ONE month by circling:
SE EV
IT
0 if it is never a problem
1 if it is almost never a problem
R
2 if it is sometimes a problem
3 if it is often a problem
4 if it is almost always a problem
There are no right or wrong answers.

U
If you do not understand a question, please ask for help.

T
O
N
O
D
PedsQL™ Infant Scales 1-12 months Not to be reproduced without permission Copyright © 1998 JW Varni, Ph.D. All rights reserved
1/10
PedsQL-Infant(1-12Months) - United States/English - Mapi.
PedsQL-Infant(1-12Months)_AU1.0_eng-USori.doc
PedsQL 2
In the past ONE month, how much of a problem has your child had with …
PHYSICAL FUNCTIONING (problems with...) Never Almost Some- Often Almost
Never times Always
1. Low energy level 0 1 2 3 4
2. Difficulty participating in active play 0 1 2 3 4
3. Having hurts or aches 0 1 2 3 4
4. Feeling tired 0 1 2 3 4
5. Being lethargic 0 1 2 3 4
6. Resting a lot 0 1 2 3 4
N
O
PHYSICAL SYMPTOMS (problems with…) Never Almost Some- Often Almost
SI
Never times Always
1. Having gas 0 1 2 3 4
IS
2. Spitting up after eating 0 1 2 3 4
M
3. Difficulty breathing 0 1 2 3 4
U PY
4. Being sick to his/her stomach
R
0 1 2 3 4
5. Difficulty swallowing 0 1 2 3 4
PE
6. Being constipated
O O 0 1 2 3 4
H C
7. Having a rash 0 1 2 3 4
8. Having diarrhea
T 0 1 2 3 4
W IEW
9. Wheezing 0 1 2 3 4
10. Vomiting 0 1 2 3 4
SE EV
IT
EMOTIONAL FUNCTIONING (problems with…) Never Almost Some- Often Almost

R
Never times Always

1. Feeling afraid or scared 0 1 2 3 4
2. Feeling angry 0 1 2 3 4
3. Crying or fussing when left alone 0 1 2 3 4
U
4. Difficulty soothing himself/herself when upset 0 1 2 3 4

T
5. Difficulty falling asleep 0 1 2 3 4

O
6. Crying or fussing while being cuddled 0 1 2 3 4

N
7. Feeling sad 0 1 2 3 4
8. Difficulty being soothed when picked up or held 0 1 2 3 4
O
9. Difficulty sleeping mostly through the night 0 1 2 3 4

D
10. Crying a lot 0 1 2 3 4

11. Feeling cranky 0 1 2 3 4
12. Difficulty taking naps during the day 0 1 2 3 4
1/10
PedsQL 3
SOCIAL FUNCTIONING (problems with…) Never Almost Some- Often Almost

Never times Always
1. Not smiling at others 0 1 2 3 4
2. Not laughing when tickled 0 1 2 3 4
3. Not making eye contact with a caregiver 0 1 2 3 4
4. Not laughing when cuddled 0 1 2 3 4
N
COGNITIVE FUNCTIONING (problems with…) Never Almost Some- Often Almost
O
Never times Always
1. Not imitating caregivers’ actions 0 1 2 3 4
SI
2. Not imitating caregivers’ facial expressions 0 1 2 3 4
IS
3. Not imitating caregivers’ sounds 0 1 2 3 4
4. Not able to fix his/her attention on objects
M
0 1 2 3 4
U PY
R
PE
O O
H C
T
W IEW
SE EV
IT
U R
T
O
N
O
D
1/10
ID#
Date:
™
PedsQL
N
O
Infant Scales
SI
IS
M
U PY
R
PE
O O DIRECTIONS
H C
T
W IEW
during the past ONE month by circling:
SE EV
IT

R

U
T
O
N
O
D
1/10
PedsQL 2
PHYSICAL FUNCTIONING (problems with…) Never Almost Some- Often Almost
Never times Always
7. Feeling too tired to play 0 1 2 3 4
N
8. Difficulty walking 0 1 2 3 4
O
9. Difficulty running a short distance without falling 0 1 2 3 4
SI
IS
Never times Always
1. Having gas 0 1 2 3 4
M
U PY
R
PE
4. Being sick to his/her stomach O O 0 1 2 3 4
5. Difficulty swallowing 0 1 2 3 4
H C
6. Being constipated T 0 1 2 3 4
W IEW
8. Having diarrhea 0 1 2 3 4
9. Wheezing 0 1 2 3 4
SE EV
IT
10. Vomiting 0 1 2 3 4
R

Never times Always
U

T

O

N

O

D

10. Crying a lot 0 1 2 3 4
1/10
PedsQL 3

Never times Always
5. Being uncomfortable around other children 0 1 2 3 4
N
Never times Always
O
SI
IS
4. Not able to fix his/her attention on objects 0 1 2 3 4
M
5. Not imitating caregivers’ speech 0 1 2 3 4
U PY
R
6. Difficulty pointing to his/her body parts when asked 0 1 2 3 4
PE
7. Difficulty naming familiar objects O O 0 1 2 3 4
8. Difficulty repeating words 0 1 2 3 4
H C
9. Difficulty keeping his/her attention on things T 0 1 2 3 4
W IEW
SE EV
IT
U R
T
O
N
O
D
1/10
ID# _________________
Date:________________
™
PedsQL
N
O
SI
Infant Scales
IS
M
U PY
R
Acute Version
PE
O O
H C
T DIRECTIONS
W IEW
SE EV
during the past 7 days by circling:

IT
R

U

T

O
N
O
D
PedsQL™ Infant Scales 1-12 Acute Not to be reproduced without permission Copyright© 1998 JW Varni, Ph.D. All rights reserved
1/10
PedsQL-3.0-InfantScales(1-12months)-Acute_United States/English
PedsQL-3.0-InfantScales(1-12months)-Acute_AU3.0_eng-USori
PedsQL 2
In the past 7 days, how much of a problem has your child had with …

Never times Always
N
O
SI
Never times Always
IS
1. Having gas 0 1 2 3 4
M
U PY
R
4. Being sick to his/her stomach 0 1 2 3 4
PE
5. Difficulty swallowing O O 0 1 2 3 4
6. Being constipated 0 1 2 3 4
H C
7. Having a rash T 0 1 2 3 4
W IEW
9. Wheezing 0 1 2 3 4
10. Vomiting 0 1 2 3 4
SE EV
IT

R
Never times Always

U

T

O

N
O

D
10. Crying a lot 0 1 2 3 4

1/10
PedsQL 3

Never times Always
N
Never times Always
O
SI
IS
M
U PY
R
PE
O O
H C
T
W IEW
SE EV
IT
U R
T
O
N
O
D
1/10
ID# _________________
Date:________________
™
PedsQL
N
O
SI
Infant Scales
IS
M
U PY
R
Acute Version
PE
O O
H C
T DIRECTIONS
W IEW
SE EV
during the past 7 days by circling:

IT
R

U

T

O
N
O
D
1/10
PedsQL-3.0-InfantScales(13-24months)-Acute – United States/English
PedsQL 2

Never times Always
N
7. Feeling too tired to play 0 1 2 3 4
O
8. Difficulty walking 0 1 2 3 4
SI
9. Difficulty running a short distance without falling 0 1 2 3 4
IS
M
Never times Always
1. Having gas 0 1 2 3 4
U PY
R
PE
O O
4. Being sick to his/her stomach 0 1 2 3 4
H C
5. Difficulty swallowing T 0 1 2 3 4
W IEW
6. Being constipated 0 1 2 3 4
SE EV
IT
9. Wheezing 0 1 2 3 4
10. Vomiting 0 1 2 3 4
R

Never times Always
U
T

O

N

O
D

10. Crying a lot 0 1 2 3 4
1/10
PedsQL 3

Never times Always
5. Being uncomfortable around other children 0 1 2 3 4
N
O
Never times Always
SI
IS
M
5. Not imitating caregivers’ speech 0 1 2 3 4
U PY
R
6. Difficulty pointing to his/her body parts when asked 0 1 2 3 4
PE
7. Difficulty naming familiar objects O O 0 1 2 3 4
8. Difficulty repeating words 0 1 2 3 4
H C
9. Difficulty keeping his/her attention on things T 0 1 2 3 4
W IEW
SE EV
IT
U R
T
O
N
O
D
1/10

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ID#

There are no right or wrong answers.

If you do not understand a question, please ask for help.

EMOTIONAL FUNCTIONING (problems with…) Never Almost Some- Often Almost

Never times Always

4. Difficulty soothing himself/herself when upset 0 1 2 3 4

5. Difficulty falling asleep 0 1 2 3 4

6. Crying or fussing while being cuddled 0 1 2 3 4

9. Difficulty sleeping mostly through the night 0 1 2 3 4

10. Crying a lot 0 1 2 3 4

SOCIAL FUNCTIONING (problems with…) Never Almost Some- Often Almost

during the past ONE month by circling:

1 if it is almost never a problem

There are no right or wrong answers.

EMOTIONAL FUNCTIONING (problems with…) Never Almost Some- Often Almost

3. Crying or fussing when left alone 0 1 2 3 4

4. Difficulty soothing himself/herself when upset 0 1 2 3 4

5. Difficulty falling asleep 0 1 2 3 4

6. Crying or fussing while being cuddled 0 1 2 3 4

8. Difficulty being soothed when picked up or held 0 1 2 3 4

9. Difficulty sleeping mostly through the night 0 1 2 3 4

SOCIAL FUNCTIONING (problems with…) Never Almost Some- Often Almost

during the past 7 days by circling:

1 if it is almost never a problem

There are no right or wrong answers.

If you do not understand a question, please ask for help.

PHYSICAL FUNCTIONING (problems with…) Never Almost Some- Often Almost

EMOTIONAL FUNCTIONING (problems with…) Never Almost Some- Often Almost

Never times Always

4. Difficulty soothing himself/herself when upset 0 1 2 3 4

5. Difficulty falling asleep 0 1 2 3 4

6. Crying or fussing while being cuddled 0 1 2 3 4

9. Difficulty sleeping mostly through the night 0 1 2 3 4

10. Crying a lot 0 1 2 3 4

SOCIAL FUNCTIONING (problems with…) Never Almost Some- Often Almost

during the past 7 days by circling:

1 if it is almost never a problem

There are no right or wrong answers.

If you do not understand a question, please ask for help.

PHYSICAL FUNCTIONING (problems with…) Never Almost Some- Often Almost

EMOTIONAL FUNCTIONING (problems with…) Never Almost Some- Often Almost

3. Crying or fussing when left alone 0 1 2 3 4

4. Difficulty soothing himself/herself when upset 0 1 2 3 4

5. Difficulty falling asleep 0 1 2 3 4

8. Difficulty being soothed when picked up or held 0 1 2 3 4

SOCIAL FUNCTIONING (problems with…) Never Almost Some- Often Almost

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