Multicultural Quality of Life Index

Multicultural Quality of Life Index
(Adapted from Mezzich, Cohen, Ruiperez, Liu & Yoon, 1999)
Name*
Date*

MonthDayYear
Instructions: Please indicate the quality of your health and life at present, from “poor” (1) to “excellent” (10), by selecting any of the ten points on the line for each of the following items:
1. Physical Well-Being (feeling energetic, free of pain and physical problems)

12345678910
2. Mental/Emotional Well-Being (feeling good, comfortable with yourself, clear headed)

12345678910
3. Self-Care and Independent Functioning (carrying out daily living tasks; making own decisions)

12345678910
4. Occupational Functioning (able to carry out work, school and parenting duties)

12345678910
5. Interpersonal Functioning (able to respond and related well to family, friends, and groups)

12345678910
6. Social-Emotional Support (availability of people you can trust and who can offer help and emotional support)

12345678910
7. Community and Services Support (pleasant and safe neighborhood, access to financial, informational and other resources)

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8. Personal Fulfillment (experiencing a sense of balance, pride and satisfaction; finding joy in life; doing things that make me happy)

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9. Spiritual Fulfillment (experiencing faith, religion or other spiritual happiness beyond my material possessions)

12345678910
10. General Perception of Quality of Life (feeling satisfied and happy with your life in general)

12345678910
Average Score:
Q1

12345678910
Q2

12345678910
Q3

12345678910
Q4

12345678910
Q5

12345678910
Q6

12345678910
Q7

12345678910
Q8

12345678910
Q9

12345678910
Q10

12345678910
Should be Empty: