EQ-5D EQ-5D Your Name Date of Birth Gender ---FemaleMale Surgery Dr Date UNDER EACH HEADING, PLEASE SELECT THE STATEMENT THAT BEST DESCRIBES YOUR HEALTH TODAY. MOBILITY ---1 I have no problems in walking about2 I have slight problems in walking about3 I have moderate problems in walking about4 I have severe problems in walking about5 I am unable to walk about SELF-CARE ---1 I have no problems washing or dressing myself2 I have slight problems washing or dressing myself3 I have moderate problems washing or dressing myself4 I have severe problems washing or dressing myself5 I am unable to wash or dress myself USUAL ACTIVITIES (e.g. work, study, housework, family or leisure activities) ---1 I have no problems doing my usual activities2 I have slight problems doing my usual activities3 I have moderate problems doing my usual activities4 I have severe problems doing my usual activities5 I am unable to do my usual activities PAIN / DISCOMFORT ---1 I have no pain or discomfort2 I have slight pain or discomfort3 I have moderate pain or discomfort4 I have severe pain or discomfort5 I have extreme pain or discomfort ANXIETY / DEPRESSION ---1 I am not anxious or depressed2 I am slightly anxious or depressed3 I am moderately anxious or depressed4 I am severely anxious or depressed5 I am extremely anxious or depressed We would like to know how good or bad your health is TODAY. On a scale of 0 to 100 (where 100 means the best health you can imagine and 0 means the worst health you can imagine), please input a number appropriate to you. THANK YOU FOR COMPLETING THIS QUESTIONNAIRE STAFF USE ONLY Participants NHS Number: Researchers Name: NHS Site Number:
