Health Related Quality of Life Questionnaire

The health related quality of life questionnaire helps in evaluating a country’s advancement in achieving the health goal of the population of the country also measuring the effectiveness of health care. This questionnaire is used by health organizations. The questionnaire also refers to a person’s social, mental and physical well being.

Sample Health Related Quality of Life Questionnaire:

Name: __________________

Date of birth: _________________

Sex: _______________

Marital status: ___________

No. of children (if any): ______________

Physical address: ______________________

1. How often do you go for a medical checkup?

a) Once a week or more

b) Once a month or more

c) Once in three months or more

d) Once in six months or more

e) Once in a year

f) Only if required

2. How often do you eat outside?

a) Once a week or more

b) Once a month or more

c) Once in three months or more

d) Once in six months or more

e) Once in a year

f) Never

3. Do you workout?

a) Yes

b) No

4. If the answer to the above question is yes, how often do you workout?

a) Once a week

b) Twice a week

c) Thrice a week

d) Four days a week

e) Five days a week

f) Six days a week

5. Are you involved in any outdoor sports?

a) Yes

b) No

6. Do you feel tired after working for a short span of time?

a) Yes

b) No

7. Do you have an active sexual life?

a) Yes

b) No

8. Do you consider yourself healthy?

a) Yes

b) No

Category: Health Questionnaire