Concept

Question

Coded Level

Under each heading, please tick the ONE box that best describes your health TODAY

Mobility

I have no problems in walking about

1

I have slight problems in walking about

2

I have moderate problems in walking about

3

I have severe problems in walking about

4

I am unable to walk about

5

Self-Care

I have no problems washing or dressing myself

1

I have slight problems washing or dressing myself

2

I have moderate problems washing or dressing myself

3

I have severe problems washing or dressing myself

4

I am unable to wash or dress myself

5

Usual Activities (e.g. work, study, housework, family or leisure activities)

I have no problems doing my usual activities

1

I have slight problems doing my usual activities

2

I have moderate problems doing my usual activities

3

I have severe problems doing my usual activities

4

I am unable to do my usual activities

5

Pain/Discomfort

I have no pain or discomfort

1

I have slight pain or discomfort

2

I have moderate pain or discomfort

3

I have severe pain or discomfort

4

I have extreme pain or discomfort

5

Anxiety/Depression

I am not anxious or depressed

1

I am slightly anxious or depressed

2

I am moderately anxious or depressed

3

I am severely anxious or depressed

4

I am extremely anxious or depressed

5