پرسشنامه کیفیت زندگی در کودکان و نوجوانان مبتلا به بیماری کیستیک فیبرووزیس

پرسشنامه کیفیت زندگی کودکان و نوجوانان مبتلا به کیستیک فیبرووزیس

همراه با پاسخنامه Scoring

CYSTIC FIBROSIS QUESTIONNAIRE-REVISED

Form1- Children Ages 6 to 11 (Interviewer Format)

This questionnaire is formatted for use by an interviewer. Please use this format for younger children. For older
children who seem able to read and answer the questions on their own, such as 12 and 13 year olds, use this
questionnaire in its self-report format.
There are directions for the interviewer for each section of the questionnaire. Directions that you should read to
the child are indicated by quotation marks. Directions that you are to follow are underlined and set in italics.
Interviewer: Please ask the following questions.

A. What is your date of birth?

- - / - - / - -

B. Are you?
☐ Male
☐ Female

C. During the past two weeks, have you been on
vacation or out of school for reasons NOT
related to your health?
☐ Yes
☐ No

D. Which of the following best describes your racial background?
☐ Caucasian
☐ African American
☐ Hispanic
☐ Asian/Oriental or Pacific Islander
☐ Native American or Native Alaskan
☐ Other (please describe)
_____________________________
☐ Prefer not to answer this question

E. What grade are you in now? (If summer, grade just finished)
Kindergarten
☐ 1st grade
☐ 2nd grade
☐ 3rd grade
☐ 4th grade
☐ 5th grade
☐ 6th grade
☐ 7th grade
☐ Not in school

Interviewer: Please read the following to the child:
“These questions are for children like you who have cystic fibrosis. Your answers will help us understand what this disease is like and how your treatments help you. So, answering these questions will help you and others like you in the future.”
"For each question that I ask, choose one of the answers on the cards I’m about to show you."

Present the orange card to the child.
"Look at this card and read with me what it says: very true, mostly true, somewhat true, not at all true."
"Here’s an example: If I asked you if it is very true, mostly true, somewhat true, not at all true that elephants can fly, which one of the four answers on the card would you choose?"

Present the blue card to the child.
"Now, look at this card and read with me what it says: always / often / sometimes / never."
"Here’s another example: If I asked you if you go to the moon always, often, sometimes, or never, which answer on the card would you choose?"

Present the orange card to the child.
"Now, I will ask you some questions about your everyday life."
"Tell me if you find the statements I read to you to be very true, mostly true, somewhat true, or not at all true."

Please check the box indicating the child's response.

“During the past two weeks”:

You were able to walk as fast as others ...........................................