Read EQ - 5D text version

Case ID Number FI ID Number Today's Date: ___ / ___ / ___

Self-Completion Booklet

Conducted by Research Triangle Institute

On Behalf of The University of Arizona Center for Health Outcomes and PharmacoEconomic Research

April 2002

Form # 2

OWN HEALTH QUESTIONS

By placing a checkmark in one box in each group below, please indicate which statements best describe your own health state today.

Mobility I have no problems in walking about I have some problems in walking about I am confined to bed 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 Usual Activities (e.g., 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 Pain/Discomfort I have no pain or discomfort I have moderate pain or discomfort I have extreme pain or discomfort Anxiety/Depression I am not anxious or depressed I am moderately anxious or depressed I am extremely anxious or depressed

Please tell your interviewer when you have finished.

1

CATEGORY RATING THERMOMETER

For Office Use Only

1. 2. 3. 4. 5.

Best imaginable health state 100

9 0

8 0

6. 7. 8.

7 0

6 0

9. 10. 11.

5 0

4 0

12. 13. 14.

3 0

2 0

15.

1 0

0 Worst imaginable health state

2

OWN HEALTH SCALE

For Office Use Only

1.

Best imaginable health state 100

9 0

8 0

7 0

6 0

5 0

4 0

3 0

2 0

1 0

0 Worst imaginable health state

3

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EQ - 5D

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