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EUROQOL (EQ-5D)

Now I am going to read some statements about aspects of your health. Please tell me which statement best describes your own health today. Mobility Thinking about your health today, which of the following statements best describes your mobility? I have no problems walking about I have some problems in walking about I am confined to bed. Self-care Thinking about your health today, which of the following statements best describes your 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 activity Thinking about your health today, which of the following statements best describes your usual activities such as work, study, housework, family or leisure activities? I have no problems with performing my usual activities I have some problems performing my usual activities I am unable to perform my usual activities. Pain/discomfort Thinking about your health today, which of the following statements best describes any pain or discomfort you may be experiencing? I have no pain or discomfort I have moderate pain or discomfort I have extreme pain or discomfort.

PLEASE TICK ONE BOX

O O O

PLEASE TICK ONE BOX

O O O

PLEASE TICK ONE BOX

O O O

PLEASE TICK ONE BOX

O O O

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more on evaluation

Anxiety/depression Thinking about your health today, which of the following statements best describes any anxiety and depression you may be experiencing? I am not anxious or depressed I am moderately anxious or depressed I am extremely anxious or depressed. Now I would like you to think of a scale between 0 and 100, where 0 is the worst health you can imagine and 100 is the best you can imagine. What number between 0 and 100 best describes your health today?

PLEASE TICK ONE BOX

O O O

(0­100) ________

Thank you.

Source: The EuroQol Group

BUILDING HEALTHY COMMUNITIES · A guide for community projects

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