EQ5D health questionnaire

When your back hurts, you may find it difficult to do some of the things you normally do.

This list contains sentences that people have used to describe themselves when they have back pain. When you read them, you may find that some stand out because they describe you today .

As you read the list, think of yourself today. When you read a sentence that describes you today, put a tick against it. If the sentence does not describe you, then leave the space blank and go on to the next one. Remember, only tick the sentence if you are sure it describes you today .

Name*
MM slash DD slash YYYY
Under each heading, please tick the ONE box that best describes your health TODAY.
MOBILITY*
SELF-CARE*
USUAL ACTIVITIES*
(e.g. work, study, housework, family or leisure activities)
PAIN / DISCOMFORT*
ANXIETY / DEPRESSION*

We would like to know how good or bad your health is TODAY. This scale is numbered from 0 to 100.

100 means the best health you can imagine.

0 means the worst health you can imagine.

Please mark an X on the scale to indicate how your health is TODAY.