1) Mobility:

I have no problems in walking about

I have some problems in walking about

I am confined to bed

2) Self care:

I have no problems with self-care

I have some problems washing or dressing myself

I am unable to wash or dress myself

3) Usual activity:

I have no problems with performing my usual activities

I have some problems with performing my usual activities

I am unable to perform my usual activities

4) Pain/discomfort:

I have no pain or discomfort

I have moderate pain or discomfort

I have extreme pain or discomfort

5) Anxiety/depression:

I am not anxious or depressed

I am moderately anxious or depressed

I am extremely anxious or depressed

6) Health state index: