0 Never – 1 Almost Never – 2 Sometimes – 3 Often – 4 Almost Always – Unknown or Not Documented Keeping up with school schoolwork: 0 Never – 1 Almost Never – 2 Sometimes – 3 Often – 4 Almost Always – Unknown or Not Documented Missing school because of not feeling well: 0 Never – 1 Almost Never – 2 Sometimes – 3 Often – 4 Almost Always – Unknown or Not Documented Missing school to go to the doctor or hospital: 0 Never – 1 Almost Never – 2 Sometimes – 3 Often – 4 Almost Always – Unknown or Not Documented VADQoL: Child (for children > 8yrs of age) or Did the child complete a form? Yes, No, Unknown. Yes or No If no, please enter the reason the VADQoL form was not completed: Too Sick Administrative (check specific reason) Urgent implant, no time Coordinator too busy or forgot Unable to contact patient Other reason, specify __________ If yes, the VAD QOL (Child form opens see attached form) – VAD QOL The VAD noise bothers me when I am awake: Always Very Sometimes Rarely Never Comments
0 – Never 1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented Keeping up with school schoolwork: 0 – Never 1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented Missing school because of not feeling well: 0 – Never 1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented Missing school to go to the doctor or hospital: 0 – Never 1 – Almost Never 2 – Sometimes 3 – Often 4 – Almost Always Unknown or Not Documented VADQoL: Child (for children > 8yrs of age) Did the child complete a form? Yes, No, or Unknown. Yes or No If no, please enter the reason the VADQoL form was not completed: Too Sick Administrative (check specific reason) Urgent implant, no time Coordinator too busy or forgot Unable to contact patient Other reason, specify __________ If yes, the VAD QOL (Child form opens – see attached form) VAD QOL The VAD noise bothers me when I am awake: Always Very Sometimes Rarely Never Comments
Pedimacs_Users_Guide_v5_0_2017_09_08.docx