<!-- BEGIN [% component.name %] -->
<p align="center">
[% entry.first_name | ucfirst %] [% entry.last_name | upper %]
:: [% INCLUDE site/nhs_number.tt nhs_number = entry.nhs_number %]
:: [% entry.dob.strftime('%d.%b.%Y') %]
</p>
<h2>Assessing your current health state </h2>
<table class="eq5d">
<tr>
<td valign="top">
<div style="border: solid 1px #000; padding: 0.5em">
<p class="classname">
To help people say how good or bad a health state is, we have drawn a
scale (rather like a thermometer) on which the best state you can imagine
is marked 100 and the worst state you can imagine is marked 0.
</p>
<p class="classname">
We would like you to indicate on this scale how good or bad your own
health is today, in your opinion. Please do this by drawing a line
from the cross to whichever point on the scale indicates how good
or bad your health state is today.
</p>
<table>
<tr>
<td><b>Worst Health State</b></td>
<td align="center" width="80%">
<span style="font-weight: bold; font-size: xx-large">X</span>
</td>
<td align="right"><b>Best Health State</b></td>
</tr>
<tr>
<td colspan="3">
<image src="/images/eq5d_scale.png" width="680" height="78" />
</td>
</table>
</div>
</td>
</tr>
<tr>
<td valign="top">
<div style="border: solid 1px #000; padding: 0.5em">
<p class="classname">
By placing a tick in one box in each group below, please indicate
which statements best describe your own health state today.
</p>
<!-- mobility -->
<p class="classname">
<div class="strong">Mobility</div>
<div>
<input type="text" />
I have no problems in walking about
</div>
<div>
<input type="text" />
I have some problems in walking about
</div>
<div>
<input type="text" />
I am confined to bed
</div>
</p>
<!-- self care -->
<p class="classname">
<div class="strong">Self-Care</div>
<div>
<input type="text" />
I have no problems with self-care
</div>
<div>
<input type="text" />
I have some problems washing or dressing myself
</div>
<div>
<input type="text" />
I am unable to wash or dress myself
</div>
</p>
<!-- usual activities -->
<p class="classname">
<div>
<span class="strong">Usual Activities</span>
(e.g. work, study, housework, family or leisure activities)
</div>
<div>
<input type="text" />
I have no problems with performing my usual activities
</div>
<div>
<input type="text" />
I have some problems with performing my usual activities
</div>
<div>
<input type="text" />
I am unable to perform my usual activities
</div>
</p>
<!-- pain & discomfort -->
<p class="classname">
<div class="strong">Pain/Discomfort</div>
<div>
<input type="text" />
I have no pain or discomfort
</div>
<div>
<input type="text" />
I have moderate pain or discomfort
</div>
<div>
<input type="text" />
I have extreme pain or discomfort
</div>
</p>
<!-- anxiety & depression -->
<p class="classname">
<div class="strong">Anxiety/Depression</div>
<div>
<input type="text" />
I am not anxious or depressed
</div>
<div>
<input type="text" />
I am moderately anxious or depressed
</div>
<div>
<input type="text" />
I am extremely anxious or depressed
</div>
</div>
</p>
<p class="classname">
Please continue overleaf if you would like to expand on any of the
sections above.
</p>
</td>
</tr>
</table>
<p class="eq5d" style="page-break-after: always">
© 1998 EuroQol GroupEQ-5D<sup>TM</sup> is a trade mark of the EuroQol Group
</p>
<!-- END [% component.name %] -->