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<!-- BEGIN outreach/questionnaire/eq5d.tt -->
  <div class="indent">
    <h4 class="blue">EQ5D assessment:</h4>
    
    <table class="xborders">
		<tr> 
			<td>
        <p class="title">1) Mobility:</p>
        <div class="indent">
          <div>
            <input type="radio" name="mobility" value="A"
              [% 'checked' IF questionnaire.eq5d.mobility == 'A' %] />
            I have no problems in walking about
          </div>
          <div>
            <input type="radio" name="mobility" value="B" 
              [% 'checked' IF questionnaire.eq5d.mobility == 'B' %] />
            I have some problems in walking about
          </div>
          <div>
            <input type="radio" name="mobility" value="C" 
              [% 'checked' IF questionnaire.eq5d.mobility == 'C' %] />
            I am confined to bed 
          </div>
        </div>
      </td> 
    </tr>

		<tr> 
			<td>
        <p class="title">2) Self care:</p>
        <div class="indent">
          <div>
            <input type="radio" name="self_care" value="A" 
              [% 'checked' IF questionnaire.eq5d.self_care == 'A' %] />
            I have no problems with self-care 
          </div>
          <div>
            <input type="radio" name="self_care" value="B" 
              [% 'checked' IF questionnaire.eq5d.self_care == 'B' %] />
            I have some problems washing or dressing myself 
          </div>
          <div>
            <input type="radio" name="self_care" value="C" 
              [% 'checked' IF questionnaire.eq5d.self_care == 'C' %] />
            I am unable to wash or dress myself 
          </div>
        </div>
      </td> 
    </tr>

		<tr> 
			<td>
        <p class="title">3) Usual activity:</p>
        <div class="indent">
          <div>
            <input type="radio" name="usual_activity" value="A"
              [% 'checked' IF questionnaire.eq5d.usual_activity == 'A' %] />
            I have no problems with performing my usual activities 
          </div>
          <div>
            <input type="radio" name="usual_activity" value="B"
              [% 'checked' IF questionnaire.eq5d.usual_activity == 'B' %] />
            I have some problems with performing my usual activities  
          </div>
          <div>
            <input type="radio" name="usual_activity" value="C"
              [% 'checked' IF questionnaire.eq5d.usual_activity == 'C' %] />
            I am unable to perform my usual activities 
          </div>
        </div>
      </td> 
    </tr>

		<tr> 
			<td>
        <p class="title">4) Pain/discomfort:</p>
        <div class="indent">
          <div>
            <input type="radio" name="discomfort" value="A"
              [% 'checked' IF questionnaire.eq5d.discomfort == 'A' %] />
            I have no pain or discomfort 
          </div>
          <div>
            <input type="radio" name="discomfort" value="B" 
              [% 'checked' IF questionnaire.eq5d.discomfort == 'B' %] />
            I have moderate pain or discomfort 
          </div>
          <div>
            <input type="radio" name="discomfort" value="C" 
            [% 'checked' IF questionnaire.eq5d.discomfort == 'C' %] />
            I have extreme pain or discomfort  
          </div>
        </div>
      </td> 
    </tr> 

		<tr> 
			<td>
        <p class="title">5) Anxiety/depression:</p>
        <div class="indent">
          <div>
            <input type="radio" name="anxiety" value="A"
              [% 'checked' IF questionnaire.eq5d.anxiety == 'A' %] />
            I am not anxious or depressed 
          </div>
          <div>
            <input type="radio" name="anxiety" value="B"
              [% 'checked' IF questionnaire.eq5d.anxiety == 'B' %] />
            I am moderately anxious or depressed 
          </div>
          <div>
            <input type="radio" name="anxiety" value="C"
              [% 'checked' IF questionnaire.eq5d.anxiety == 'C' %] />
            I am extremely anxious or depressed  
          </div>
        </div>
      </td> 
    </tr>

		<tr> 
			<td>
        <p class="title">6) Health state index:
          <input type="text" name="health_index" size="2"
            value="[% questionnaire.eq5d.health_index %]" />
        </p>
      </td>
    </tr>
    </table>
  </div>
<!-- END outreach/questionnaire/eq5d.tt -->