EQ-5D

The EQ-5D is a self-report measure of health status. It also includes a 'visual analogue' scale, so that the individual can rate their health from a 0 (worst) to 100 (best) state.

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Unique ID (2-4 digits) *

Your unique ID that will have been given to you before being asked to fill in this form. Please get in touch if you can't remember it.

Initials (Optional)

This just makes it quicker for us to know who completed the form.

Date and time that form was completed: *

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Date

Time

By selecting one box/ circle from each group below, please indicate which statement best describes your health state today.

Mobility *

• 1) I have no problems walking about
• 2) I have some problems walking about
• 3) I am confined to bed

Self-care *

• 1) I have no problems with self-care
• 2) I have some problems washing or dressing myself
• 3) I am unable to wash or dress myself

Usual activities (e.g. work, study, housework, family, or leisure activities) *

• 1) I have no problems with performing my usual activities
• 2) I have some problems performing my usual activities
• 3) I am unable to perform my usual activities

Pain/ Discomfort *

• 1) I have no pain or discomfort
• 2) I have moderate pain or discomfort
• 3) I have extreme pain or discomfort

Anxiety/ Depression *

• 1) I am not anxious or depressed
• 2) I am moderately anxious or distressed
• 3) I am extremely anxious or depressed

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 marked 100 and the worst state you can imagine is marked by 0.

We would like you to indicate on this scale how good or bad your own health is today, in your opinion. Please do this by using the slider below to indicate how good or bad your health state is.

Health state

Selected Value: 0

Enter any other information that you would like us to know about:

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