Measuring Loneliness Scale
First Name
*
Last Name
*
DOB:
*
UCLA3
*
Hardly ever
Some of the time
Often
How often do you feel that you lack companionship?
Hardly ever
Some of the time
Often
How often do you feel left out?
Hardly ever
Some of the time
Often
How often do you feel isolated from others?
Hardly ever
Some of the time
Often
Assessment
*
Source: Campaign to End Loneliness (UCLA Loneliness Scale, 2004)
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