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<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">
<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 an arrow
next to whichever point on the scale indicates how good or bad your
health state is today.
</p>
</td>
<td rowspan="2" align="center">
<p class="smaller">Best imaginable health state</p>
<image src="/images/eq5d.png" />
<div>0</div>
<p class="smaller">Worst imaginable health state</p>
</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">Self-Care</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">
© 1998 EuroQol GroupEQ-5D<sup>TM</sup> is a trade mark of the EuroQol Group
</p>
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