Rc peds ql epilepsy module_2018-01-05_all_standard_acute

PedsQL Epilepsy Module 3.0 Parent (2-4) Not to be reproduced without permission Copyright © 1998 JW Varni, Ph.D. All rights reserved
9.26
PedsQL-3.0-Epilepsy-PT – United States/English – Original version
PedsQL-3.0-Epilepsy-PT_AU3.0_eng-USori
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Version 3.0
PARENT REPORT for TODDLERS (ages 2-4)
DIRECTIONS
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:
0 if it is never a problem
1 if it is almost never a problem
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.
If you do not understand a question, please ask for help.
ID# _________________________
Date:________________________
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PedsQL – Epilepsy Module 2
PedsQL Epilepsy Module Parent 3.0 (2-4) Not to be reproduced without permission Copyright © 1998 JW Varni, Ph.D. All rights reserved
9.26
PedsQL-3.0-Epilepsy-PT – United States/English – Original version
PedsQL-3.0-Epilepsy-PT_AU3.0_eng-USori
In the past ONE month, how much of a problem has your child had with…
IMPACT Never Almost
Never
Some-
times
Often Almost
Always
1. My child has trouble doing the same physical
activities or sports as other kids
0 1 2 3 4
2. My child has trouble being as independent in daily
tasks (e.g., dressing) as other kids his/her age
0 1 2 3 4
3. My child’s activities are restricted due to epilepsy 0 1 2 3 4
4. My child has trouble taking his/her epilepsy
medicine or doing other treatments (e.g., a special
diet)
0 1 2 3 4
5. My child has trouble avoiding seizure triggers (e.g.,
flashing lights, being tired)
0 1 2 3 4
6. My child misses preschool/daycare or social
activities because of epilepsy and/or its treatments
0 1 2 3 4
COGNITIVE FUNCTIONING Never Almost
Never
Some-
times
Often Almost
Always
1. My child has trouble thinking quickly 0 1 2 3 4
2. My child has trouble remembering things 0 1 2 3 4
3. My child has trouble learning new things 0 1 2 3 4
4. My child needs extra help at preschool/daycare 0 1 2 3 4
5. My child has trouble understanding what he/she
reads
0 1 2 3 4
EXECUTIVE FUNCTIONING Never Almost
Never
Some-
times
Often Almost
Always
1. My child has trouble sitting still 0 1 2 3 4
2. It is hard for my child to do what he/she is told 0 1 2 3 4
3. My child has trouble paying attention 0 1 2 3 4
4. My child has trouble finishing things he/she started 0 1 2 3 4
SLEEP/FATIGUE Never Almost
Never
Some-
times
Often Almost
Always
1. My child feels tired during the day 0 1 2 3 4
2. My child has trouble sleeping (e.g., falling and
staying asleep)
0 1 2 3 4
MOOD/BEHAVIOR Never Almost
Never
Some-
times
Often Almost
Always
1. My child feels grouchy 0 1 2 3 4
2. My child feels angry 0 1 2 3 4
3. My child feels sad or blue 0 1 2 3 4
4. My child feels afraid or scared 0 1 2 3 4
5. My child is easily frustrated 0 1 2 3 4
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PedsQL Epilepsy Module 3.0 (5-7) Not to be reproduced without permission Copyright © 1998 JW Varni, Ph.D. All rights reserved
9.26
PedsQL-3.0-Epilepsy-YC – United States/English – Original version
PedsQL-3.0-Epilepsy-YC_AU3.0_eng-USori
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Version 3.0
YOUNG CHILD REPORT (ages 5-7)
Instructions for interviewer:
I am going to ask you some questions about things that might be a problem for some children.
I want to know how much of a problem any of these things might be for you.
Show the child the template and point to the responses as you read.
If it is not at all a problem for you, point to the smiling face
If it is sometimes a problem for you, point to the middle face
If it is a problem for you a lot, point to the frowning face
I will read each question. Point to the pictures to show me how much of a problem it is for
you. Let’s try a practice one first.
Not at all Sometimes A lot
Is it hard for you to snap your fingers
☺
Ask the child to demonstrate snapping his or her fingers to determine whether or not the question was
answered correctly. Repeat the question if the child demonstrates a response that is different from
his or her action.
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PedsQL - Epilepsy Module 2
9.26
Think about how you have been doing for the last few weeks. Please listen carefully to each
sentence and tell me how much of a problem this is for you.
After reading the item, gesture to the template. If the child hesitates or does not seem to understand
how to answer, read the response options while pointing at the faces.
IMPACT Not
at all
Some-
times
A lot
1. Is it hard for you to do the same physical activities or sports as
other kids (like play games at recess)?
0 2 4
2. Do you need more help from adults than other kids your age? 0 2 4
3. Are there things you are not allowed to do because of your
epilepsy?
0 2 4
4. Is it hard for you to take your epilepsy medicine and/or do your
treatments (like following a special diet)?
0 2 4
5. Does it bother you that your parents are around you more in
case you have a seizure (like having to play at your own house
instead of at a friend’s house)?
0 2 4
6. Do you miss school or fun activities because of your epilepsy? 0 2 4
7. Do you feel different from other kids or family members? 0 2 4
8. Do you feel embarrassed when a seizure happens? 0 2 4
COGNITIVE FUNCTIONING Not
at all
Some-
times
A lot
1. Do you have trouble thinking fast? 0 2 4
2. Do you have trouble remembering things? 0 2 4
3. Do you have trouble learning new things? 0 2 4
4. Do you need extra help at school (e.g., tutor, extra time on
tests)?
0 2 4
5. Do you have trouble keeping up with your school work? 0 2 4
6. Do you have trouble understanding what you read? 0 2 4
SLEEP/FATIGUE Not
at all
Some-
times
A lot
1. Are you tired during the day? 0 2 4
2. Do you have trouble sleeping (e.g., falling and staying asleep)? 0 2 4
3. Do you need more sleep than other kids? 0 2 4
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9.26
EXECUTIVE FUNCTIONING Not
at all
Some-
times
A lot
1. Do you have trouble keeping your room clean or losing things? 0 2 4
2. Do you have trouble doing what you are told? 0 2 4
3. Do you have trouble paying attention? 0 2 4
4. Do you have trouble finishing things you have started (like
homework, games, or chores)?
0 2 4
5. Do you do things without thinking them through first? 0 2 4
6. Is it hard for you to sit still? 0 2 4
MOOD/BEHAVIOR Not
at all
Some-
times
A lot
1. Do you feel grouchy? 0 2 4
2. Do you feel angry? 0 2 4
3. Do you feel sad or blue? 0 2 4
4. Do you feel scared about a lot of things? 0 2 4
5. Do you get easily frustrated? 0 2 4
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9.26
How much of a problem is this for you?
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9.26
PedsQL-3.0-Epilepsy-PYC – United States/English – Original version
PedsQL-3.0-Epilepsy-PYC_AU3.0_eng-USori
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Version 3.0
PARENT REPORT for YOUNG CHILDREN (ages 5-7)
DIRECTIONS
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9.26
IMPACT Never Almost
Never
Some-
times
Often Almost
Always
0 1 2 3 4
0 1 2 3 4
medicine or doing other treatments (e.g. a special
diet)
0 1 2 3 4
0 1 2 3 4
6. My child misses school or social activities because
of epilepsy and/or its treatments
0 1 2 3 4
7. My child does not like being left alone in case
he/she has a seizure
0 1 2 3 4
8. My child feels different from other kids or family
members
0 1 2 3 4
9. My child feels embarrassed when a seizure
happens
0 1 2 3 4
Never
Some-
times
Often Almost
Always
4. My child needs extra help at school 0 1 2 3 4
reads
0 1 2 3 4
6. My child has trouble keeping up with schoolwork 0 1 2 3 4
Never
Some-
times
Often Almost
Always
staying asleep)
0 1 2 3 4
3. My child needs more sleep than other kids 0 1 2 3 4
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9.26
Never
Some-
times
Often Almost
Always
Never
Some-
times
Often Almost
Always
5. My child acts without thinking 0 1 2 3 4
6. My child has trouble staying organized 0 1 2 3 4
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9.26
PedsQL-3.0-Epilepsy-C – United States/English – Original version
PedsQL-3.0-Epilepsy-C_AU3.0_eng-USori
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Version 3.0
CHILD REPORT (ages 8-12)
DIRECTIONS
On the following page is a list of things that might be a problem for you.
Please tell us how much of a problem each one has been for you during
the past ONE month by circling:
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9.26
In the past ONE month, how much of a problem has this been for you …
IMPACT Never Almost
Never
Some-
times
Often Almost
Always
1. It is hard for me to do the same physical activities or
sports as other kids
0 1 2 3 4
2. It is hard for me to do daily tasks on my own
compared to other kids (e.g., riding bikes)
0 1 2 3 4
3. I am not allowed to do activities because of my
epilepsy
0 1 2 3 4
4. It is hard for me to take epilepsy medicine and/or
other treatments (e.g., a special diet)
0 1 2 3 4
5. I do not like being left alone in case I have a seizure 0 1 2 3 4
6. I miss school or social activities because of epilepsy
and/or its treatments
0 1 2 3 4
7. I feel different from other kids or family members 0 1 2 3 4
8. I feel embarrassed when a seizure happens 0 1 2 3 4
9. It is hard for me to avoid seizure triggers (e.g.,
0 1 2 3 4
Never
Some-
times
Often Almost
Always
1. It is hard for me to think quickly 0 1 2 3 4
2. It is hard for me to remember things 0 1 2 3 4
3. It is hard for me to learn new things 0 1 2 3 4
4. I need extra help at school (e.g., tutor, extra time on
tests)
0 1 2 3 4
5. It is hard for me to keep up with schoolwork 0 1 2 3 4
6. It is hard for me to understand what I read 0 1 2 3 4
Never
Some-
times
Often Almost
Always
1. I feel tired during the day 0 1 2 3 4
2. It is hard for me to sleep (e.g., falling and staying
asleep)
0 1 2 3 4
3. I need more sleep than other kids 0 1 2 3 4
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9.26
In the past ONE month, how much of a problem has this been for you …
Never
Some-
times
Often Almost
Always
1. It is hard for me to stay organized 0 1 2 3 4
2. It is hard for me to do what I am told 0 1 2 3 4
3. It is hard for me to pay attention 0 1 2 3 4
4. It is hard for me to finish things I started 0 1 2 3 4
5. I act without thinking 0 1 2 3 4
6. It is hard for me to sit still 0 1 2 3 4
Never
Some-
times
Often Almost
Always
1. I feel grouchy 0 1 2 3 4
2. I feel angry 0 1 2 3 4
3. I feel sad or blue 0 1 2 3 4
4. I feel afraid or scared 0 1 2 3 4
5. I feel easily frustrated 0 1 2 3 4
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9.26
PedsQL-3.0-Epilepsy-PC – United States/English – Original version
PedsQL-3.0-Epilepsy-PC_AU3.0_eng-USori
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Version 3.0
PARENT REPORT for CHILDREN (ages 8-12)
DIRECTIONS
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9.26
In the past ONE month, how much of a problem has your child had with …
IMPACT Never Almost
Never
Some-
times
Often Almost
Always
0 1 2 3 4
2. My child has trouble being as independent as other
kids his/her age in daily tasks (e.g., riding bikes)
0 1 2 3 4
diet)
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
members
0 1 2 3 4
happens
0 1 2 3 4
Never
Some-
times
Often Almost
Always
reads
0 1 2 3 4
Never
Some-
times
Often Almost
Always
staying asleep)
0 1 2 3 4
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9.26
In the past ONE month, how much of a problem has your child had with …
Never
Some-
times
Often Almost
Always
Never
Some-
times
Often Almost
Always
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9.26
PedsQL-3.0-Epilepsy-A – United States/English – Original version
PedsQL-3.0-Epilepsy-A_AU3.0_eng-USori
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Version 3.0
TEEN REPORT (ages 13-18)
DIRECTIONS
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PedsQL Epilepsy Module 2
9.26
In the past ONE month, how much of a problem has this been for you…
IMPACT Never Almost
Never
Some-
times
Often Almost
Always
sports as other teens
0 1 2 3 4
2. It is hard for me to be as independent as other
teens my age (e.g., driving, riding bikes)
0 1 2 3 4
epilepsy
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
7. I feel different from other teens or family members 0 1 2 3 4
0 1 2 3 4
Never
Some-
times
Often Almost
Always
tests)
0 1 2 3 4
Never
Some-
times
Often Almost
Always
asleep)
0 1 2 3 4
3. I need more sleep than other teens 0 1 2 3 4
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9.26
Never
Some-
times
Often Almost
Always
Never
Some-
times
Often Almost
Always
4. I feel tense or anxious 0 1 2 3 4
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9.26
PedsQL-3.0-Epilepsy-PA – United States/English – Original version
PedsQL-3.0-Epilepsy-PA_AU3.0_eng-USori
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Version 3.0
PARENT REPORT for TEENS (ages 13-18)
DIRECTIONS
On the following page is a list of things that might be a problem for your teen.
Please tell us how much of a problem each one has been for your teen
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9.26
In the past ONE month, how much of a problem has your teen had with…
IMPACT Never Almost
Never
Some-
times
Often Almost
Always
1. My teen has trouble doing the same physical
activities or sports as other teens
0 1 2 3 4
2. My teen has trouble being as independent as other
teens his/her age (e.g., driving, riding bikes)
0 1 2 3 4
3. My teen’s activities are restricted due to epilepsy 0 1 2 3 4
4. My teen has trouble taking his/her epilepsy
diet)
0 1 2 3 4
5. My teen has trouble avoiding seizure triggers (e.g.,
0 1 2 3 4
6. My teen misses school or social activities because
0 1 2 3 4
7. My teen does not like being left alone in case
0 1 2 3 4
8. My teen feels different from other teens or family
members
0 1 2 3 4
9. My teen feels embarrassed when a seizure
happens
0 1 2 3 4
Never
Some-
times
Often Almost
Always
1. My teen has trouble thinking quickly 0 1 2 3 4
2. My teen has trouble remembering things 0 1 2 3 4
3. My teen has trouble learning new things 0 1 2 3 4
4. My teen needs extra help at school 0 1 2 3 4
5. My teen has trouble understanding what he/she
reads
0 1 2 3 4
6. My teen has trouble keeping up with schoolwork 0 1 2 3 4
Never
Some-
times
Often Almost
Always
1. My teen feels tired during the day 0 1 2 3 4
2. My teen has trouble sleeping (e.g., falling and
staying asleep)
0 1 2 3 4
3. My teen needs more sleep than other teens 0 1 2 3 4
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9.26
In the past ONE month, how much of a problem has your teen had with…
Never
Some-
times
Often Almost
Always
1. My teen has trouble sitting still 0 1 2 3 4
2. It is hard for my teen to do what he/she is told 0 1 2 3 4
3. My teen has trouble paying attention 0 1 2 3 4
4. My teen has trouble finishing things he/she started 0 1 2 3 4
5. My teen acts without thinking 0 1 2 3 4
6. My teen has trouble staying organized 0 1 2 3 4
Never
Some-
times
Often Almost
Always
1. My teen feels grouchy 0 1 2 3 4
2. My teen feels angry 0 1 2 3 4
3. My teen feels sad or blue 0 1 2 3 4
4. My teen feels tense or anxious 0 1 2 3 4
5. My teen is easily frustrated 0 1 2 3 4
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9.26
PedsQL-3.0-Epilepsy-YAd – United States/English – Original version
PedsQL-3.0-Epilepsy-YAd_AU3.0_eng-USori
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Version 3.0
YOUNG ADULT REPORT (ages 18-25)
DIRECTIONS
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9.26
IMPACT Never Almost
Never
Some-
times
Often Almost
Always
sports as other young adults
0 1 2 3 4
young adults my age (e.g., driving)
0 1 2 3 4
epilepsy
0 1 2 3 4
0 1 2 3 4
6. I miss school/work or social activities because of
epilepsy and/or its treatments
0 1 2 3 4
7. I feel different from other young adults or family
members
0 1 2 3 4
0 1 2 3 4
Never
Some-
times
Often Almost
Always
4. I need extra help at school/work (e.g., tutor, extra
time on tests/work)
0 1 2 3 4
5. It is hard for me to keep up with schoolwork/work 0 1 2 3 4
Never
Some-
times
Often Almost
Always
asleep)
0 1 2 3 4
3. I need more sleep than other young adults 0 1 2 3 4
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9.26
Never
Some-
times
Often Almost
Always
Never
Some-
times
Often Almost
Always
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9.26
PedsQL-3.0-Epilepsy-PYAd – United States/English – Original version
PedsQL-3.0-Epilepsy-PYAd_AU3.0_eng-USori
P
Pe
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Version 3.0
PARENT REPORT for YOUNG ADULTS (ages 18-25)
DIRECTIONS
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9.26
PedsQL-3.0-Epilepsy-PYAd– United States/English – Original version
IMPACT Never Almost
Never
Some-
times
Often Almost
Always
activities or sports as other young adults
0 1 2 3 4
young adults his/her age (e.g., driving)
0 1 2 3 4
diet)
0 1 2 3 4
0 1 2 3 4
6. My child misses school/work or social activities
because of epilepsy and/or its treatments
0 1 2 3 4
0 1 2 3 4
8. My child feels different from other young adults or
family members
0 1 2 3 4
happens
0 1 2 3 4
Never
Some-
times
Often Almost
Always
4. My child needs extra help at school/work 0 1 2 3 4
reads
0 1 2 3 4
6. My child has trouble keeping up with
schoolwork/work
0 1 2 3 4
Never
Some-
times
Often Almost
Always
staying asleep)
0 1 2 3 4
3. My child needs more sleep than other young adults 0 1 2 3 4
R
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p
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D
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n
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9.26
PedsQL-3.0-Epilepsy-PYAd– United States/English – Original version
Never
Some-
times
Often Almost
Always
Never
Some-
times
Often Almost
Always
4. My child feels tense or anxious 0 1 2 3 4
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9.26
PedsQL-3.0-Epilepsy-Acute-PT – United States/English – Original version
PedsQL-3.0-Epilepsy-Acute-PT_AU3.0_eng-USori
P
Pe
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sQ
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Acute Version 3.0
PARENT REPORT for TODDLERS (ages 2-4)
DIRECTIONS
during the past 7 days by circling:
ID# _________________________
Date:________________________
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PedsQL Epilepsy Module Parent 3.0 (2-4) Not to be reproduced without permission Copyright © 1998 JW Varni, Ph.D. All rights reserved
9.26
PedsQL-3.0-Epilepsy-Acute-PT – United States/English – Original version
PedsQL-3.0-Epilepsy-Acute-PT_AU3.0_eng-USori
In the past 7 days, how much of a problem has your child had with…
IMPACT Never Almost
Never
Some-
times
Often Almost
Always
0 1 2 3 4
0 1 2 3 4
diet)
0 1 2 3 4
0 1 2 3 4
6. My child misses preschool/daycare or social
activities because of epilepsy and/or its treatments
0 1 2 3 4
Never
Some-
times
Often Almost
Always
4. My child needs extra help at preschool/daycare 0 1 2 3 4
reads
0 1 2 3 4
Never
Some-
times
Often Almost
Always
Never
Some-
times
Often Almost
Always
staying asleep)
0 1 2 3 4
Never
Some-
times
Often Almost
Always
R
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v
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w
C
o
p
y
D
o
n
o
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h
o
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p
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m
i
s
s
i
o
n

9.26
PedsQL-3.0-Epilepsy-Acute-YC – United States/English – Original version
PedsQL-3.0-Epilepsy-Acute-YC_AU3.0_eng-USori
P
Pe
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sQ
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Acute Version 3.0
YOUNG CHILD REPORT (ages 5-7)
Instructions for interviewer:
I am going to ask you some questions about things that might be a problem for some children.
I want to know how much of a problem any of these things might be for you.
Show the child the template and point to the responses as you read.
If it is not at all a problem for you, point to the smiling face
If it is sometimes a problem for you, point to the middle face
If it is a problem for you a lot, point to the frowning face
I will read each question. Point to the pictures to show me how much of a problem it is for
you. Let’s try a practice one first.
Is it hard for you to snap your fingers
☺
Ask the child to demonstrate snapping his or her fingers to determine whether or not the question was
answered correctly. Repeat the question if the child demonstrates a response that is different from
his or her action.
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9.26
Think about how you have been doing for the past 7 days. Please listen carefully to each
sentence and tell me how much of a problem this is for you.
After reading the item, gesture to the template. If the child hesitates or does not seem to understand
how to answer, read the response options while pointing at the faces.
IMPACT Not
at all
Some-
times
A lot
1. Is it hard for you to do the same physical activities or sports as
other kids (like play games at recess)?
0 2 4
2. Do you need more help from adults than other kids your age? 0 2 4
3. Are there things you are not allowed to do because of your
epilepsy?
0 2 4
4. Is it hard for you to take your epilepsy medicine and/or do your
treatments (like following a special diet)?
0 2 4
5. Does it bother you that your parents are around you more in
case you have a seizure (like having to play at your own house
instead of at a friend’s house)?
0 2 4
6. Do you miss school or fun activities because of your epilepsy? 0 2 4
7. Do you feel different from other kids or family members? 0 2 4
8. Do you feel embarrassed when a seizure happens? 0 2 4
COGNITIVE FUNCTIONING Not
at all
Some-
times
A lot
1. Do you have trouble thinking fast? 0 2 4
2. Do you have trouble remembering things? 0 2 4
3. Do you have trouble learning new things? 0 2 4
4. Do you need extra help at school (e.g., tutor, extra time on
tests)?
0 2 4
5. Do you have trouble keeping up with your school work? 0 2 4
6. Do you have trouble understanding what you read? 0 2 4
SLEEP/FATIGUE Not
at all
Some-
times
A lot
1. Are you tired during the day? 0 2 4
2. Do you have trouble sleeping (e.g., falling and staying asleep)? 0 2 4
3. Do you need more sleep than other kids? 0 2 4
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9.26
Remember, think about how you have been doing for the past 7 days…
EXECUTIVE FUNCTIONING Not
at all
Some-
times
A lot
1. Do you have trouble keeping your room clean or losing things? 0 2 4
2. Do you have trouble doing what you are told? 0 2 4
3. Do you have trouble paying attention? 0 2 4
4. Do you have trouble finishing things you have started (like
homework, games, or chores)?
0 2 4
5. Do you do things without thinking them through first? 0 2 4
6. Is it hard for you to sit still? 0 2 4
MOOD/BEHAVIOR Not
at all
Some-
times
A lot
1. Do you feel grouchy? 0 2 4
2. Do you feel angry? 0 2 4
3. Do you feel sad or blue? 0 2 4
4. Do you feel scared about a lot of things? 0 2 4
5. Do you get easily frustrated? 0 2 4
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9.26
How much of a problem is this for you?
☺ R
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9.26
PedsQL-3.0-Epilepsy-Acute-PYC – United States/English – Original version
PedsQL-3.0-Epilepsy-Acute-PYC_AU3.0_eng-USori
P
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Acute Version 3.0
PARENT REPORT for YOUNG CHILDREN (ages 5-7)
DIRECTIONS
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9.26
IMPACT Never Almost
Never
Some-
times
Often Almost
Always
0 1 2 3 4
0 1 2 3 4
medicine or doing other treatments (e.g. a special
diet)
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
members
0 1 2 3 4
happens
0 1 2 3 4
Never
Some-
times
Often Almost
Always
reads
0 1 2 3 4
Never
Some-
times
Often Almost
Always
staying asleep)
0 1 2 3 4
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v
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w
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9.26
Never
Some-
times
Often Almost
Always
Never
Some-
times
Often Almost
Always
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9.26
PedsQL-3.0-Epilepsy-Acute-C – United States/English – Original version
PedsQL-3.0-Epilepsy-Acute-C_AU3.0_eng-USori
P
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Acute Version 3.0
CHILD REPORT (ages 8-12)
DIRECTIONS
the past 7days by circling:
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9.26
In the past 7 days, how much of a problem has this been for you …
IMPACT Never Almost
Never
Some-
times
Often Almost
Always
sports as other kids
0 1 2 3 4
2. It is hard for me to do daily tasks on my own
compared to other kids (e.g., riding bikes)
0 1 2 3 4
epilepsy
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
7. I feel different from other kids or family members 0 1 2 3 4
0 1 2 3 4
Never
Some-
times
Often Almost
Always
tests)
0 1 2 3 4
Never
Some-
times
Often Almost
Always
asleep)
0 1 2 3 4
3. I need more sleep than other kids 0 1 2 3 4
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v
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D
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9.26
In the past 7 days, how much of a problem has this been for you …
Never
Some-
times
Often Almost
Always
Never
Some-
times
Often Almost
Always
4. I feel afraid or scared 0 1 2 3 4
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9.26
PedsQL-3.0-Epilepsy-Acute-PC – United States/English – Original version
PedsQL-3.0-Epilepsy-Acute-PC_AU3.0_eng-USori
P
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QL
L™
™
E
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Acute Version 3.0
PARENT REPORT for CHILDREN (ages 8-12)
DIRECTIONS
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9.26
In the past 7 days, how much of a problem has your child had with …
IMPACT Never Almost
Never
Some-
times
Often Almost
Always
0 1 2 3 4
kids his/her age in daily tasks (e.g., riding bikes)
0 1 2 3 4
diet)
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
members
0 1 2 3 4
happens
0 1 2 3 4
Never
Some-
times
Often Almost
Always
reads
0 1 2 3 4
Never
Some-
times
Often Almost
Always
staying asleep)
0 1 2 3 4
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9.26
In the past 7 days, how much of a problem has your child had with …
Never
Some-
times
Often Almost
Always
Never
Some-
times
Often Almost
Always
R
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v
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9.26
PedsQL-3.0-Epilepsy-Acute-A – United States/English – Original version
PedsQL-3.0-Epilepsy-Acute-A_AU3.0_eng-USori
P
Pe
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sQ
QL
L™
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E
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Acute Version 3.0
TEEN REPORT (ages 13-18)
DIRECTIONS
the past 7 days by circling:
R
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p
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D
o
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9.26
In the past 7 days, how much of a problem has this been for you…
IMPACT Never Almost
Never
Some-
times
Often Almost
Always
sports as other teens
0 1 2 3 4
teens my age (e.g., driving, riding bikes)
0 1 2 3 4
epilepsy
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
7. I feel different from other teens or family members 0 1 2 3 4
0 1 2 3 4
Never
Some-
times
Often Almost
Always
tests)
0 1 2 3 4
Never
Some-
times
Often Almost
Always
asleep)
0 1 2 3 4
3. I need more sleep than other teens 0 1 2 3 4
R
e
v
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w
C
o
p
y
D
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9.26
Never
Some-
times
Often Almost
Always
Never
Some-
times
Often Almost
Always
R
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9.26
PedsQL-3.0-Epilepsy-Acute-PA – United States/English – Original version
PedsQL-3.0-Epilepsy-Acute-PA_AU3.0_eng-USori
P
Pe
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ds
sQ
QL
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Acute Version 3.0
PARENT REPORT for TEENS (ages 13-18)
DIRECTIONS
On the following page is a list of things that might be a problem for your teen.
Please tell us how much of a problem each one has been for your teen
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9.26
In the past 7 days, how much of a problem has your teen had with…
IMPACT Never Almost
Never
Some-
times
Often Almost
Always
1. My teen has trouble doing the same physical
activities or sports as other teens
0 1 2 3 4
2. My teen has trouble being as independent as other
teens his/her age (e.g., driving, riding bikes)
0 1 2 3 4
3. My teen’s activities are restricted due to epilepsy 0 1 2 3 4
4. My teen has trouble taking his/her epilepsy
diet)
0 1 2 3 4
5. My teen has trouble avoiding seizure triggers (e.g.,
0 1 2 3 4
6. My teen misses school or social activities because
0 1 2 3 4
7. My teen does not like being left alone in case
0 1 2 3 4
8. My teen feels different from other teens or family
members
0 1 2 3 4
9. My teen feels embarrassed when a seizure
happens
0 1 2 3 4
Never
Some-
times
Often Almost
Always
1. My teen has trouble thinking quickly 0 1 2 3 4
2. My teen has trouble remembering things 0 1 2 3 4
3. My teen has trouble learning new things 0 1 2 3 4
4. My teen needs extra help at school 0 1 2 3 4
5. My teen has trouble understanding what he/she
reads
0 1 2 3 4
6. My teen has trouble keeping up with schoolwork 0 1 2 3 4
Never
Some-
times
Often Almost
Always
1. My teen feels tired during the day 0 1 2 3 4
2. My teen has trouble sleeping (e.g., falling and
staying asleep)
0 1 2 3 4
3. My teen needs more sleep than other teens 0 1 2 3 4
R
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v
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w
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p
y
D
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n

9.26
In the past 7 days, how much of a problem has your teen had with…
Never
Some-
times
Often Almost
Always
1. My teen has trouble sitting still 0 1 2 3 4
2. It is hard for my teen to do what he/she is told 0 1 2 3 4
3. My teen has trouble paying attention 0 1 2 3 4
4. My teen has trouble finishing things he/she started 0 1 2 3 4
5. My teen acts without thinking 0 1 2 3 4
6. My teen has trouble staying organized 0 1 2 3 4
Never
Some-
times
Often Almost
Always
1. My teen feels grouchy 0 1 2 3 4
2. My teen feels angry 0 1 2 3 4
3. My teen feels sad or blue 0 1 2 3 4
4. My teen feels tense or anxious 0 1 2 3 4
5. My teen is easily frustrated 0 1 2 3 4
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9.26
PedsQL-3.0-Epilepsy-Acute-YAd – United States/English – Original version
PedsQL-3.0-Epilepsy-Acute-YAd_AU3.0_eng-USori
P
Pe
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ds
sQ
QL
L™
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E
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Acute Version 3.0
YOUNG ADULT REPORT (ages 18-25)
DIRECTIONS
the past 7 days by circling:
R
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v
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p
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D
o
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9.26
IMPACT Never Almost
Never
Some-
times
Often Almost
Always
sports as other young adults
0 1 2 3 4
young adults my age (e.g., driving)
0 1 2 3 4
epilepsy
0 1 2 3 4
0 1 2 3 4
6. I miss school/work or social activities because of
epilepsy and/or its treatments
0 1 2 3 4
7. I feel different from other young adults or family
members
0 1 2 3 4
0 1 2 3 4
Never
Some-
times
Often Almost
Always
4. I need extra help at school/work (e.g., tutor, extra
time on tests/work)
0 1 2 3 4
5. It is hard for me to keep up with schoolwork/work 0 1 2 3 4
Never
Some-
times
Often Almost
Always
asleep)
0 1 2 3 4
3. I need more sleep than other young adults 0 1 2 3 4
R
e
v
i
e
w
C
o
p
y
D
o
n
o
t
u
s
e
w
i
t
h
o
u
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p
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r
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i
s
s
i
o
n

9.26
Never
Some-
times
Often Almost
Always
Never
Some-
times
Often Almost
Always
R
e
v
i
e
w
C
o
p
y
D
o
n
o
t
u
s
e
w
i
t
h
o
u
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p
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r
m
i
s
s
i
o
n

9.26
PedsQL-3.0-Epilepsy-Acute-PYAd – United States/English – Original version
PedsQL-3.0-Epilepsy-Acute-PYAd_AU3.0_eng-USori
P
Pe
ed
ds
sQ
QL
L™
™
E
Ep
pi
il
le
ep
ps
sy
y M
Mo
od
du
ul
le
e
Acute Version 3.0
PARENT REPORT for YOUNG ADULTS (ages 18-25)
DIRECTIONS
R
e
v
i
e
w
C
o
p
y
D
o
n
o
t
u
s
e
w
i
t
h
o
u
t
p
e
r
m
i
s
s
i
o
n

9.26
PedsQL-3.0-Epilepsy-Acute-PYAd– United States/English – Original version
IMPACT Never Almost
Never
Some-
times
Often Almost
Always
activities or sports as other young adults
0 1 2 3 4
young adults his/her age (e.g., driving)
0 1 2 3 4
diet)
0 1 2 3 4
0 1 2 3 4
6. My child misses school/work or social activities
because of epilepsy and/or its treatments
0 1 2 3 4
0 1 2 3 4
8. My child feels different from other young adults or
family members
0 1 2 3 4
happens
0 1 2 3 4
Never
Some-
times
Often Almost
Always
4. My child needs extra help at school/work 0 1 2 3 4
reads
0 1 2 3 4
6. My child has trouble keeping up with
schoolwork/work
0 1 2 3 4
Never
Some-
times
Often Almost
Always
staying asleep)
0 1 2 3 4
3. My child needs more sleep than other young adults 0 1 2 3 4
R
e
v
i
e
w
C
o
p
y
D
o
n
o
t
u
s
e
w
i
t
h
o
u
t
p
e
r
m
i
s
s
i
o
n

9.26
PedsQL-3.0-Epilepsy-Acute-PYAd– United States/English – Original version
Never
Some-
times
Often Almost
Always
Never
Some-
times
Often Almost
Always
4. My child feels tense or anxious 0 1 2 3 4
R
e
v
i
e
w
C
o
p
y
D
o
n
o
t
u
s
e
w
i
t
h
o
u
t
p
e
r
m
i
s
s
i
o
n

Rc peds ql epilepsy module_2018-01-05_all_standard_acute

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