<!-- 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">
      &copy; 1998 EuroQol GroupEQ-5D<sup>TM</sup> is a trade mark of the EuroQol Group
    </p>
<!-- END [% component.name %] -->
