There are 4 components and 11 factors that constitute quality of life for the Older Adult. On the table below grade yourself on each of the factors. Any score less than a 3 would indicate that an improvement in this area is warranted and that you should strategize on how to improve this area in your life.
| Component | Factor | 1(lowest) | 2 | 3 | 4(Highest) |
| 1. Health & Fitness | |||||
| 1. Health Status | |||||
| 2. Physical Function | |||||
| 3. Sexual Function | |||||
| 4. Energy & Vitality | |||||
| 2. Cognitive and Emotional | |||||
| 1. Emotional Function | |||||
| 2. Feeling of Wellbeing | |||||
| 3. Life Satisfaction | |||||
| 4. Cognitive Function | |||||
| 3. Social and Recreation | |||||
| 1. Social Function | |||||
| 2. Recreational Activity | |||||
| 3. Economic Status | |||||
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