ANNEXE 3 :
QUESTIONNAIRE DE QUALITE DE
VIE (WHOQOL-OLD)
How much do you worry about what the future might
hold?
Not at all A little A moderate amount
Very much An extreme amount
1 2 3
4 5
1.(F25.1) To what extent do impairments to your senses (e.g.
hearing, vision, taste, smell, touch) affect your daily life?
Not at all A little A moderate amount Very
much An extreme amount
1 2 3
4 5
2. (F25.3) To what extent does loss of for example, hearing,
vision, taste, smell or touch affect your ability to participate in
activities?
Not at all A little A moderate amount Very
much An extreme amount
1 2 3
4 5
3. (F26.1) How much freedom do you have to make your own
decisions?
Not at all A little A moderate amount Very
much An extreme amount
1 2 3
4 5
4. (F26.2) To what extent do you feel in control of your
future?
Not at all Slightly Moderately
Very Extremely
1 2 3 4 5
5. (F26.4) How much do you feel that the people around you are
respectful of your freedom?
Not at all Slightly Moderately
Very Extremely
1 2 3
4 5
6. (F29.2) How concerned are you about the way in which you
will die?
Not at all A little A moderate amount
Very much An extreme amount
1 2 3
4 5
7. (F29.3) How much are you afraid of not being able to
control your death?
Not at all Slightly Moderately
Very Extremely
1 2 3
4 5
8. (F29.4) How scared are you of dying?
Not at all Slightly Moderately
Very Extremely
1 2 3 4
5
9. (F29.5) How much do you fear being in pain before you
die?
Not at all A little A moderate amount
Very much An extreme amount
1 2 3 4 5
10. (F25.4) To what extent do problems with your sensory
functioning (e.g. hearing, vision, taste, smell, touch) affect your ability to
interact with others?
Not at all A little Moderately
Mostly Completely
1 2 3
4 5
11. (F26.3) To what extent are you able to do the things you'd
like to do?
Not at all A little Moderately
Mostly Completely
1 2 3
4 5
12. (F27.3) To what extent are you satisfied with your
opportunities to continue achieving in life?
Not at all A little Moderately
Mostly Completely
1 2 3
4 5
13. (F27.4) How much do you feel that you have received the
recognition you deserve in life?
Not at all A little Moderately
Mostly Completely
1 2 3
4 5
14. (F28.4) To what extent do you feel that you have enough to
do each day?
Not at all A little Moderately
Mostly Completely
1 2 3
4 5
15. (F27.5) How satisfied are you with what you have achieved
in life?
Very dissatisfied Dissatisfied Neither satisfied
nor dissatisfied Satisfied Very satisfied
1 2
3 4
5
16. (F28.1) How satisfied are you with the way you use your
time?
Very dissatisfied Dissatisfied Neither satisfied
nor dissatisfied Satisfied Very satisfied
1 2
3 4
5
17. (F28.2) How satisfied are you with your level of
activity?
Very dissatisfied Dissatisfied Neither satisfied
nor dissatisfied Satisfied Very satisfied
1 2
3 4
5
18. (F28.7) How satisfied are you with your opportunity to
participate in community activities?
Very dissatisfied Dissatisfied Neither satisfied nor
dissatisfied Satisfied Very satisfied
1 2 3 4 5
19. (F27.1) How happy are you with the things you are able to
look forward to?
Very unhappy Unhappy Neither happy nor
unhappy Happy Very happy
1 2
3 4
5
20. (F25.2) How would you rate your sensory functioning (e.g.
hearing, vision, taste, smell, touch)?
Very poor Poor Neither poor
nor good Good Very good
1 2
3 4 5
21. (F30.2) To what extent do you feel a sense of
companionship in your life?
Not at all A little A moderate amount
Very much An extreme amount
1 2
3 4 5
22. (F30.3) To what extent do you experience love in your
life?
Not at all A little A moderate amount
Very much An extreme amount
1 2 3 4 5
23. (F30.4) To what extent do you have opportunities to
love?
Not at all A little Moderately
Mostly Completely
1 2 3 4
5
24. (F30.7) To what extent do you have opportunities to be
loved?
Not at all A little Moderately
Mostly Completely
1 2 3
4 5
How much do you worry about what the future might
hold?
Not at all A little A moderate amount
Very much An extreme amount
1 2 3
4 5
Thank you for your help
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