QOL/Adherence Forms

These questionnaires/interviews were developed by the Pediatric AIDS Clinical Trials Group sponsored by the NIH/NIAID/NICHD.

The date following the form name is the date the form was last modified (this is the date found in the lower left corner of the form). If the date in the lower left corner of your form copy does not match the date on this web page, please download the latest version of the form. NOTE: The date in the upper right corner of a form is the date the form was added to a CRF notebook.

Learn about the IMPAACT Adherence to Therapy Subcommittee.

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Form Number Form Name Form Date English Spanish Other Translations
NPW0033 GBS Baseline and Monitoring Tool 29-MAY-2007 npw0033.pdf
NPW0035 Guillain-Barre Syndrome (GBS) Baseline and Monitoring Tool - II 09-SEP-2009 npw0035.pdf
QL0500 General Health Self-Assessment Form 06-SEP-1994 ql0500.pdf
ql0500_spa.pdf
QL0601 Overall Health Status Assessment 05-MAR-1997 ql0601.pdf
ql0601_spa.pdf
QL0602 Multidimensional Health Status Assessment 05-MAR-1997 ql0602.pdf
ql0602_spa.pdf
QL0742 ACTG Self Report 22-APR-2002 ql0742.pdf
ql0742_spa.pdf
QL4000 Quality of Life Assessment (For Ages 6 months - 4 Years) 05-JUL-2001 ql4000.pdf
ql4000_spa.pdf
QL4003 Quality of Life Assessment - Revised (For Ages 6 months - 4 Years) 15-NOV-2002 ql4003.pdf
QL4004 Quality of Life Assessment (For Ages 5 - 11 Years) 15-NOV-2002 ql4004.pdf
QL4005 Quality of Life Assessment (For Ages 12 - 20 Years) 14-MAY-2003 ql4005.pdf
QL5001 Pediatric Adherence Questionnaire Module 2 - General Reasons for Non-Adherence 05-JUL-2001 ql5001.pdf
ql5001_spa.pdf
QL5002 Pediatric Adherence Questionnaire Module 1 - Revised Behavior/Identification 05-JUL-2001 ql5002.pdf
ql5002scripts.pdf
ql5002spascripts.pdf
QL5003 Pediatric Adherence Questionnaire Module 1 - III - Behavior/Identification 22-NOV-2004 ql5003.pdf
ql5003scripts.pdf
ql5003spascripts.pdf
QL5004 Pediatric Adherence Questionnaire Module 2- Revised - General Reasons for Non-Adherence 22-NOV-2004 ql5004.pdf
QL5005 Pediatric Domestic Adherence Questionnaire 19-SEP-2006 ql5005.pdf
ql5005_spa.pdf
QL5010 Perinatal Adherence Questionnaire Module 2 - General Reasons for Non-Adherence 05-JUL-2001 ql5010.pdf
ql5010_spa.pdf
QL5011 Perinatal Adherence Questionnaire Module 2 - Revised - General Reasons for Non-Adherence 22-NOV-2004 ql5011.pdf
QL5020 Adolescent Adherence Questionnaire Module 2 - General Reasons for Non-Adherence 05-JUL-2001 ql5020.pdf
ql5020_spa.pdf
QL5021 Adolescent Adherence Questionnaire Module 2 - Revised - General Reasons for Non-Adherence 21-NOV-2004 ql5021.pdf
QL5022 Adolescent Adherence Questionnaire 19-SEP-2006 ql5022.pdf
ql5022_spa.pdf
QL5030 Pediatric International Adherence Questionnaire - Behavior/Identification 15-OCT-2004 ql5030.pdf
ql5030scripts.pdf
ql5030sesotho.pdf
ql5030zulu.pdf
ql5030swahili.pdf
QL6000 Subject Body Image Questionnaire 13-MAR-2000 ql6000.pdf
ql6000_spa.pdf
QL6001 Caregiver Body Image Questionnaire 13-MAR-2000 ql6001.pdf
ql6001_spa.pdf
QL7000 Maternal Baseline Behavioral Self Report 20-DEC-2002 ql7000.pdf
ql7000_spa.pdf
QL7001 Maternal Behavioral Self Report 20-DEC-2002 ql7001.pdf
ql7001_spa.pdf
QLW0044 Supplemental Antepartum Adherence Questionnaire 22-OCT-2001 qlw0044.pdf
qlw0044_spa.pdf
QLW0045 Supplemental Postpartum Adherence Questionnaire 22-OCT-2001 qlw0045.pdf
qlw0045_spa.pdf