Euroqol EQ-5D

 

Please indicate which statement best describes your own health state today, by Placing a dot in a circle in each group below,

Do not select more than one option in each group

1. Mobility

I have no problems walking about
I have some problems walking about
I am confined to bed

2. Self care

I have no problems with self care
I have some problems washing or dressing myself
I am unable to wash or dress myself

3. Usual activities (eg. work, study, housework, family or leisure activities)

I have no problems with performing my usual activities
I have some problems with performing my usual activities
I am unable to perform my usual activities

4. Pain/ Discomfort

I have no pain or discomfort
I have moderate pain or discomfort
I have extreme pain or discomfort

5. Anxiety/ Depression

I am not anxious or depressed
I am moderately anxious or depressed
I am extremely anxious or depressed

6. Health state

To help people say how good or bad a health state is, we have drawn a scale (rather like a thermometer) on which the best state you can imagine is 100 and the worst state you can imagine is marked by 0.

 

Please indicate on this scale how good or bad your health state is.

 

Worst imaginable health state

 

Best imaginable health state


Author information goes here.
Copyright 1999 [OrganizationName]. All rights reserved.
Revised: 05/18/11