Quality of Life Assessment We would love to hear from you! Please fill out this form and we will get in touch with you shortly. Contact InformationName*FirstLastDay Phone*Evening Phone*EmailEnter EmailConfirm EmailBest Time to CallMorningAfternoonEveningQuality of Life AssessmentI often feel lonely even with other people*YesNoIt is difficult for me to make friends*YesNoI feel a strong need to sleep during the day*YesNoI have to read things several times before they sink in*YesNoIt takes a lot of effort for me to do a simple task*YesNoI often have to force myself to stay awake*YesNoI have a difficult time controliing my emotions*YesNoI have to struggle to finish task*YesNoI often lose track of what I want to say*YesNoI feel as if i let people down*YesNoI am easily irritated by other people*YesNoI lack confidence*YesNoI feel worn out even when I have done nothing*YesNoI find it hard to mix with people*YesNoThere are times when I feel very depressed*YesNoI find it difficult to plan ahead*YesNoI often forget what people have said to me*YesNoI feel as if i am a burden to people*YesNoI have to push myself to do things*YesNoI avoid responsibility when possible*YesNoMy memory lets me down*YesNoI often feel too tired to do the things I ought to do*YesNoI have to force myself to do all of the things that need doing*YesNoCommentsPlease explain any "yes" answer on any of the previous anwsersPlease list any medication you are takingCaptcha