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Quality of Life Index

  1. County of Placer Health and Human Services

  2. Your case number can be found on your EBT card. (Example: 1B12345)

  3. Instructions:

    Please indicate the quality of your health and life at present, from “poor” to “excellent,” by selecting any of the ten points on the line for each of the following Items:

  4. 1. Physical Well-being (feeling energetic, free of pain and physical problems)

  5. 2. Mental/Emotional Well-Being (feeling good, comfortable with yourself, clear headed)

  6. 3. Self-Care and Independent Functioning (carrying out daily living tasks; making own decisions)

  7. 4. Occupational Functioning (able to carry out work, school, and parenting duties)

  8. 5. Interpersonal Functioning (able to respond and relate well to family, friends, and groups)

  9. 6. Social-Emotional Support (availability of people you can trust and who can offer help and emotional support)

  10. 7. Community and Services Support (pleasant and safe neighborhood, access to financial, informational, and other resources)

  11. 8. Personal Fulfillment (experiencing a sense of balance, pride, and satisfaction; finding joy in life; doing things that make me happy)

  12. 9. Spiritual Fulfillment (experiencing faith, religion, or other spiritual happiness beyond my material possessions)

  13. 10. General Perception of Quality of Life (feeling satisfied and happy with your life in general)

  14. Leave This Blank:

  15. This field is not part of the form submission.