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, Jusqu'à quel âge êtes-vous allé(e) à l'école ?

, Quel est le diplôme le plus élevé que vous avez obtenu ?

D. Dépressive, CES-D ; validation française de Fuhrer & Rouillon, 1989) Questionnaire d'évaluation de la dépression, Quel est votre statut professionnel actuel ? ANNEXE 6. QUESTIONNAIRE

, Les impressions suivantes sont ressenties par la plupart des gens. Indiquez pour chaque sentiment ou comportement présenté de cette liste combien de fois vous l'avez éprouvé durant la semaine qui vient de se passer ? Cochez la case qui vous correspond

, Clinique médicale sans rendez-vous ??, vol.9, pp.678-9815

, Lieux culturels Bibliothèque .?.?, vol.9, issue.590, pp.669-5542

, Cinéma ??, vol.9, pp.656-2747

. .. ??, , p.811

. ?. Centre-de-santé-?, 9 (590) 678-5918 les résidences d'hébergement et les foyers-logements, contacter le CLSC ???, vol.9, pp.38-2642

, Ambulance??.??, vol.911

, Ligne Aide Abus Aînés ...??, vol.9, issue.590, pp.656-7274

, Prévention du Suicide ???, vol.9, issue.590, pp.695-0447

, Associations/ loisirs Association Culturelle, vol.9, issue.590, pp.634-5695

?. .. Services, , vol.9, pp.38-2642

. Télé-assistance and . ??, , vol.9, pp.669-5452

, N'ayant pas vocation à connaître une large diffusion n'a pas été reproduit ici mais

, CRIUGM, 2015.

, N'ayant pas vocation à connaître une large diffusion n'a pas été reproduit ici mais

, N'ayant pas vocation à connaître une large diffusion, ainsi que pour des raisons de

. Québec, , 2015.

, N'ayant pas vocation à connaître une large diffusion, ainsi que pour des raisons de

, Vérification : le sujet vérifie dans l'agenda le jour et l'heure proposés

, Disponibilité : le sujet indique sa disponibilité (pas fait systématiquement à haute voix, les consignes demandant « Montrez tout ce que vous devez faire pour?

, Veille : le sujet active le cellulaire (Optionnel : parfois l'écran ne se met pas en veille)

, Déblocage : le sujet appuie sur la touche étoile pour débloquer le clavier du téléphone

, Vérification : le sujet vérifie dans l'agenda le jour et l'heure proposés

, Disponibilité : le sujet indique sa disponibilité (pas fait systématiquement à haute voix, les consignes demandant « Montrez tout ce que vous devez faire pour?

, Veille : le sujet active le cellulaire (Optionnel : parfois l'écran ne se met pas en veille)

, Déblocage : le sujet appuie sur la touche étoile pour débloquer le clavier du téléphone

, Courrier : prendre le courrier

, Recherche jour et heure : rechercher le jour et l'heure du RV dans le courrier médical 4. Activation : activer la tablette 5. Agenda : ouvrir l'application agenda 6. Vérification : vérifier dans l

, Se déplacer : se déplacer dans l'agenda pour trouver la date du RV

, Disponibilité : le sujet indique sa disponibilité (pas fait systématiquement à haute voix, les consignes demandant « Montrez tout ce que vous devez faire pour?

, Accueil : revenir à l'écran d'accueil 10. Courrier : prendre le courrier

, Quelle est votre langue maternelle ? ??????????????????? 2. Sexe : o Féminin o Masculin

, Quelle est (ou était) votre profession ?

, A quel âge avez-vous commencé à aller à l'école ?

, Jusqu'à quel âge êtes-vous allé(e) à l'école ?

, Quel est le diplôme le plus élevé que vous avez obtenu ?

, En général, diriez-vous que votre santé est

, Avez-vous déjà pris des médicaments pour dormir pendant une période de plus de 6 mois consécutifs ? ¨ oui ¨ non

, Avez-vous déjà pris des médicaments pour les nerfs, pour dormir, comme des tranquillisants, des somnifères ou des antidépresseurs, pendant une période de plus de 6 mois consécutifs ? ¨ oui ¨ non

, Avez-vous été suivi(e) par un médecin ou un psychologue pour un problème psychologique pendant une période de plus de 6 mois consécutifs ? ¨ oui ¨ non

, Avez-vous des difficultés physiques (troubles auditifs, visuels?) ? ¨ oui ¨ non Précisez

, Avez-vous été hospitalisé(e) au cours des 2 derniers mois ? ¨ oui ¨ non

:. .. Précisez,

A. Beaudoin, . Desrichard, . Fournet, ;. Roulin, and . Berry, , 1989.

, Si quelqu'un vous montrait les images de 16 objets familiers (exemples : lampe, parapluie, etc.), vous pourriez regarder ces images une fois et vous rappeler le

, Après avoir lu deux fois la liste de commissions d'un ami contenant 18 articles, (exemples : fromage blanc, tomates, etc.), si vous alliez au magasin le jour même sans utiliser la liste, vous pourriez vous souvenir

, Si on vous donnait une liste de 9 chiffres (exemple : 9, 5, etc.) vous pourriez répéter juste après dans le même ordre

, Si on vous donnait 7 années (exemples : 1458, 1952, etc.) vous pourriez juste après répéter

, Si vous disposiez 18 objets familiers (exemples : carnet, clés, etc.) dans différents endroits d'une pièce, quelques minutes après vous pourriez vous rappeler où vous aviez

, Si on vous donnait 18 symboles à aligner dans différentes cases d'une grille (exemples : +, #, etc.), vous pourriez, quelques minutes plus tard, vous rappeler où vous aviez

, Je pense que je suis quelqu'un de valable, au moins autant que les autres gens

, J'aimerais pouvoir avoir plus de respect pour moi-même

, Tout bien considéré, j'ai tendance à penser que je suis un(e) raté(e)

, J'ai une opinion positive de moi-même

, * 1 point aux réponses Non et Plus ou moins

, ** 1 point aux réponses Oui et Plus ou moins

, Mesure de l'isolement relationnel (Insee, Pan Ké Shon, 2003.

, Avec combien de personnes différentes avez-vous eu une conversation d'au moins cinq minutes la semaine dernière (en face à face, par téléphone ou via messagerie instantanée) ? Attention ! Il s'agit bien du nombre de personnes différentes avec lesquelles vous

, Veuillez indiquer votre réponse : ___________________________ personnes

, Avec combien de personnes différentes avez-vous eu une conversation privée d'au moins cinq minutes la semaine dernière (en face à face, par téléphone ou via messagerie instantanée) ? Une conversation de nature privée comprend toute discussion dont le thème est en relation avec votre vie de famille

, Veuillez indiquer votre réponse : ___________________________ personnes

.. Annexe, ;. Vie-(logsdon, and . Wollak, E.A, vol.3797, 1996.

, Le QoL-AD vf est administré à des sujets atteints de démence. L'entretien doit être conduit selon les instructions suivantes

, Donner le questionnaire au sujet de façon à ce qu'il/elle puisse suivre au fur et à mesure des explications. Il est important que les textes des questions et des instructions en caractère gras soient lus tels quels

, Vous répondrez en choisissant l'une de ces 4 réponses : (montrer chacun des mots sur le questionnaire en l'énonçant) mauvais, moyen, bon ou excellent. Pensez à différents aspects de votre vie aujourd'hui, comme votre santé, votre forme, votre famille, votre situation financière, etc, Je vais vous poser quelques questions sur votre qualité de vie. J'aimerais votre avis sur différents aspects de votre vie

, (e) de bien comprendre une question, n'hésitez pas à me le dire. Si vous ne savez pas très bien quelle réponse choisir parmi les quatre, indiquez quand même celle qui vous semble la plus proche de votre situation actuelle. En général, il est assez facile de se rendre compte si le, Si vous n'êtes pas sûr

, Cependant en aucun cas, l'enquêteur ne suggérera une réponse : les quatre modalités doivent être présentées et le sujet doit faire un choix

, Le sujet doit avoir la feuille du questionnaire entre les mains, de manière à suivre

, Si le sujet a des difficultés à entourer la réponse, vous pouvez lui demander qu'il vous montre ou vous dise son choix

, Si le sujet ne parvient pas à choisir une réponse à un ou plusieurs items

, Concernant votre santé, physiquement comment ça va ? En ce moment, vous diriez que votre santé physique est mauvaise, moyenne, bonne ou excellente ? Entourez la réponse de votre choix

, Est-ce que vous vous sentez en forme ? En ce moment, vous diriez que votre forme est mauvaise, moyenne, bonne ou excellente ? Si le sujet répond que cela dépend des jours

, Ces jours-ci, comment va votre moral, votre humeur ? Vous diriez que votre moral est mauvais, moyen, bon ou excellent ?

, Que pensez-vous de votre cadre de vie, de l'endroit où vous habitez actuellement ? Vous diriez qu'il est mauvais, moyen, bon ou excellent ?

, Que pensez-vous de votre mémoire ? Vous diriez qu'elle est mauvaise, moyenne, bonne ou excellente ?

, Si le sujet dit ne pas avoir de famille, préciser en l'interrogeant à propos d'éventuels frères, soeurs, enfants, nièces, neveux ? 7. Que pensez vous de votre vie de couple ? En ce moment, vous diriez que vos relations avec X sont mauvaises, moyennes, bonnes ou excellentes ? Certains sujets seront célibataires, veufs ou divorcés. Dans ce cas, demander comment se passe la relation avec la personne la plus proche, que ce soit un membre de la famille, Comment cela se passe avec votre famille ? En ce moment, vous diriez que vos relations avec les membres de votre famille sont mauvaises, moyennes, bonnes ou excellentes

, ou que tous ses amis sont décédés, continuer par : Y a t-il quelqu'un en dehors de la famille dont vous appréciez la compagnie ? si le sujet cite quelqu'un, demander : Seriez-vous d'accord pour dire c'est un (e) ami (e) ? si oui, vous diriez que les relations avec cette personne sont mauvaises, moyennes, bonnes ou excellentes ? Si le sujet réitère sa réponse, demander : Si vous n'avez pas d'amis, vous diriez que cette situation est mauvaise, moyenne, Comment trouvez-vous vos relations en ce moment avec vos amis ? Vous diriez qu'elles sont mauvaises, moyennes, bonnes ou excellentes ? Si le sujet vous répond qu'il n'a pas d'ami, vol.3

Q. Vf,

D. , Quelle image avez-vous de vous-même en ce moment ? Quand vous pensez à ce que vous êtes, à ce qui vous caractérise, cette image est-elle mauvaise, moyenne, E.A, vol.3797, 1996.

, Que pensez-vous de votre capacité à réaliser les tâches de tous les jours comme le ménage, le bricolage ou d'autres choses que vous avez besoin de faire ? Vous diriez que votre capacité est mauvaise, moyenne

, Que pensez-vous de votre capacité à vous divertir, à faire des choses par plaisir ? Vous diriez que votre capacité à vous distraire est mauvaise, moyenne

, Que pensez-vous de votre situation financière actuelle ? Vous diriez que votre situation financière est mauvaise, moyenne, bonne ou excellente ? Si le patient hésite, lui expliquer qu'il ne s'agit pas de savoir combien il/elle a d'argent, mais simplement comment il/elle se sent vis à vis de sa situation financière

, Comment trouvez-vous votre vie dans son ensemble ? En ce moment, vous diriez que votre vie est mauvaise, moyenne, bonne ou excellente ?, Attribution du score : Les points suivants sont attribués à chaque item : Mauvais=1, Moyen=2, Bon=3