Is it hard to pay attention in school: 0 Not at all – 1 Almost Never – 2 Sometimes – 3 – 4 A lot – Unknown or Not Documented I forget things: 0 Not at all – 1 Almost Never – 2 Sometimes – 3 Often – 4 A lot – Unknown or Not Documented I have trouble keeping up with schoolwork: 0 Not at all – 1 Almost Never – 2 Sometimes – 3 – 4 A lot – Unknown or Not Documented I miss school because of not feeling well: 0 Not at all – 1 Almost Never – 2 Sometimes – 3 – 4 A lot – Unknown or Not Documented I miss school to go to the doctor or hospital: 0 Not at all – 1 Almost – 2 Sometimes – 3 – 4 A lot – Unknown or Not Documented PedsQL: Parent Did the parent complete a form? Yes, No, or Unknown. Yes or No If no, please enter the reason the PedsQL form was not completed: Too Sick Administrative (check specific reason) Urgent implant, no time Coordinator too busy or forgot Unable to contact parent Other reason, specify _______ If yes, please select the form: ‘Parent’ PedsQL Toddler (2-4yrs) PedsQL Young Child (5-7yrs)
Is it hard to pay attention in school: 0 – Not at all 1 – Almost Never 2 – Sometimes 3 – 4 – A lot Unknown or Not Documented I forget things: 0 – Not at all 1 – Almost Never 2 – Sometimes 3 – Often 4 – A lot Unknown or Not Documented I have trouble keeping up with schoolwork: 0 – Not at all 1 – Almost Never 2 – Sometimes 3 – 4 – A lot Unknown or Not Documented I miss school because of not feeling well: 0 – Not at all 1 – Almost Never 2 – Sometimes 3 – 4 – A lot Unknown or Not Documented I miss school to go to the doctor or hospital: 0 – Not at all 1 – Almost 2 – Sometimes 3 – 4 – A lot Unknown or Not Documented PedsQL: Parent Did the parent complete a form? Yes, No, or Unknown. Yes or No If no, please enter the reason the PedsQL form was not completed: Too Sick Administrative (check specific reason) Urgent implant, no time Coordinator too busy or forgot Unable to contact parent Other reason, specify _______ If yes, please select the ‘Parent’ form: PedsQL Toddler (2-4yrs) PedsQL Young Child (5-7yrs)
Pedimacs_Users_Guide_v5_0_2017_09_08.docx