ESI-55

ESI-55

 

    1. In general, would you say your health is:

    2. Overall, how would you rate your own quality-of-life?

    3. Compared to one year ago, how would you rate your health in general now?

    4. Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports

    5. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing
    golf

    6. Lifting or carrying groceries

    7. Climbing several flights of stairs

    8. Climbing one flight of stairs

    9. Bending, kneeling, or stooping

    10. Walking more than one mile

    11. Walking several blocks

    12. Walking one block

    13. Bathing and dressing yourself

    14. Cut down on the amount of time you could spend on work or other activities

    15. Accomplished less than you would like

    16. Were limited in the kind of work or other activities

    17. Had difficulty performing the work or other activities

    18. Did work or other activities less carefully than usual

    19. Cut down on the amount of time you could spend on work or other activities

    20. Accomplished less than you would like

    21. Were limited in the kind of work or other activities

    22. Had difficulty performing the work or other activities

    23. Did work or other activities less carefully than usual

    24. During the past 4 weeks, to what extend has your physical health or emotional problems interfered with your normal social activities with family, friends, neighbours, or groups?

    How much of the time during the past 4 weeks…?
    25. Did you feel full of pep?

    26. Have you been a very nervous person?

    27. Have you felt so down in the dumps that nothing could cheer you up?

    28. Have you felt calm and peaceful?

    29. Did you have a lot of energy?

    30. Have you felt downhearted and blue?

    31. Did you feel worn out?

    32. Have you been a happy person?

    33. Did you feel tired?

    34. Has your health limited your social activities (like visiting with friends or close relatives)?

    35. Have you had difficulty concentrating and thinking?

    36. Did you have trouble keeping your attention on an activity for long?

    37. Have you worried about having another seizure?

    38. Did you have difficulty reasoning and solving problems (for example, making plans, making
    decisions, learning new things?)

    39. Were you discouraged by your health problems?

    40. How much bodily pain have you had during the past 4 weeks?

    41. During the past 4 weeks, how much did bodily pain interfere with your normal work
    (including both outside the home and housework)?

    42. I seem to get sick (any kind of sickness) a little easier than other people

    43. I am as healthy as anybody I know

    44. I expect my health to get worse

    45. My health is excellent

    46. When there is an illness going around, I usually catch it

    47. I seem to get seizures a little easier than other people with epilepsy

    48. How has the quality of your life been during the past 4 weeks? That is, how have things been going for you?

    49. In the past 4 weeks, have you had any trouble with your memory?

    50. In the past 4 weeks, have you had any trouble with your speech or language?

    51. Cut down on the amount of time you could spend on work or other activities

    52. Accomplished less than you would like

    53. Were limited in the kind of work or other activities

    54. Had difficulty performing the work or other activities

    55. Did work or other activities less carefully than usual

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