Pondworks Psychiatry & Psychotherapy

Available Forms

Compliment A Pondworks Employee New Patient Form 1 of 7: Patient Contact Information New Patient Form 2 of 7: Practice Policies New Patient Form 3 of 7: Privacy Practices New Patient Form 4 of 7: Patient Portal Agreement New Patient Form 5 of 7: Review of Systems New Patient Form 6 of 7: Medications List New Patient Form 7 of 7: Consultation Informed Consent Questionnaire # 1 of 3: PHQ-9 Questionnaire # 2 of 3: GAD-7 Questionnaire # 3 of 3: Q-LES-Q-SF Telemedicine Consent Telemedicine Practice Policies

Questionnaire # 3 of 3: Q-LES-Q-SF

Quality of Life Enjoyment and Satisfaction Questionnaire

Patient initials *

Provider *

Date of appointment *

Taking everything into consideration, during the past week, how satisfied have you been with your....

...physical health? *

Very poor

Poor

Fair

Good

Very good

...mood? *

Very poor

Poor

Fair

Good

Very good

...work? *

Very poor

Poor

Fair

Good

Very good

...household activities? *

Very poor

Poor

Fair

Good

Very good

...social activities? *

Very poor

Poor

Fair

Good

Very good

...family relationships? *

Very poor

Poor

Fair

Good

Very good

...leisure time activities? *

Very poor

Poor

Fair

Good

Very good

...ability to function in daily life? *

Very poor

Poor

Fair

Good

Very good

...sexual drive, interest and/or performance?*** *

Very poor

Poor

Fair

Good

Very good

***If satisfaction is very poor, poor or fair on the item above, please write the factor(s) associated with a lack of satisfaction:

...economic status? *

Very poor

Poor

Fair

Good

Very good

...living/housing situation*** *

Very poor

Poor

Fair

Good

Very good

***If satisfaction is very poor, poor or fair on the item above, please write the factor(s) associated with a lack of satisfaction

...ability to get around physically without feeling dizzy or unsteady or falling?*** *

Very poor

Poor

Fair

Good

Very good

***If satisfaction is very poor, poor or fair on the item above, please write the factor(s) associated with a lack of satisfaction

...your vision in terms of ability to work or hobbies?*** *

Very poor

Poor

Fair

Good

Very good

***If satisfaction is very poor, poor or fair on the item above, please write the factor(s) associated with a lack of satisfaction

...overall sense of well being? *

Very poor

Poor

Fair

Good

Very good

...medication?

Very poor

Poor

Fair

Good

Very good

Are you currently taking medication? *

No, I am not taking medication

Yes, I take medication

How would you rate your overall life satisfaction and contentment during the past week? *

Very poor

Poor

Fair

Good

Very good

To Be Completed By Pondworks Staff

Column 1 total

Column 2 total

Column 3 total

Column 4 total

Column 5 total

Total

* Required field