S. No.

Domains

Items

1

Physical

1. Activities of daily living

2. Dependence on medicinal substances and medical aids

3. Energy and fatigue

4. Mobility

5. Pain and discomfort

6. Sleep and rest

7. Work Capacity

2

Psychological

1. Bodily image and appearance

2. Negative feelings

3. Positive feelings

4. Self-esteem

5. Spirituality/Religion/Personal beliefs

6. Thinking, learning, memory and concentration

3

Social

1. Personal relationships

2. Social support

3. Sexual activity

4

Environmental

1. Financial resources

2. Freedom, physical safety and security

3. Health and social care: accessibility and quality

4. Home environment

5. Opportunities for acquiring new information and skills

6. Participation in and opportunities for recreation/leisure activities

7. Physical environment (pollution/noise/traffic/climate)

8. Transport