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Forms
EQ-5D-5L Health Questionnaire

EQ-5D-5L Health Questionnaire

EQ-5D-5L Health Questionnaire

The link you have used to access this questionnaire is incorrect
If you have any queries or concerns please contact

Dale Edgar, Project Lead at
SMASHS.fitness@health.wa.gov.au

Under each heading below, please select the ONE box or answer that best describes your health TODAY.

UniqueCode Are you still awaiting your surgery or investigation? Yes No

If you are waiting, has your health condition changed since March 2020? Much worse Worse Unchanged Improved Much improved

MOBILITY I have no problems with walking around I have slight problems with walking around I have moderate problems with walking around I have severe problems with walking around I am unable to walk around PERSONAL CARE I have no problems with washing or dressing myself I have slight problems with washing or dressing myself I have moderate problems with washing or dressing myself I have severe problems with 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 doing my usual activities I have slight problems doing my usual activities I have moderate problems doing my usual activities I have severe problems doing my usual activities I am unable to do my usual activities PAIN / DISCOMFORT I have no pain or discomfort I have slight pain or discomfort I have moderate pain or discomfort I have severe pain or discomfort I have extreme pain or discomfort ANXIETY / DEPRESSION I am not anxious or depressed I am slightly anxious or depressed I am moderately anxious or depressed I am severely anxious or depressed I am extremely anxious or depressed We would like to know how GOOD or BAD your health is TODAY? Where 100 means YOU ARE IN the best health you can imagine
and 0 means YOU ARE IN the worst health you can imagine
Please indicate how your health is TODAY

Last Updated: 25/08/2023

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