EQ-5D-5L

EuroQol 5-Dimension 5-Level questionnaire for measuring health-related quality of life

Instructions:

Please answer all questions to the best of your ability.

Mobility

I have no problems in walking about

I have slight problems in walking about

I have moderate problems in walking about

I have severe problems in walking about

I am unable to walk about

Self-Care

I have no problems washing or dressing myself

I have slight problems washing or dressing myself

I have moderate problems washing or dressing myself

I have severe problems washing or dressing myself

I am unable to wash or dress myself

Usual Activities

I have no problems doing my usual activities

I have slight problems doing my usual activities

I have moderate problems doing my usual activities

I have severe problems doing my usual activities

I am unable to do my usual activities

Pain / Discomfort

I have no pain or discomfort

I have slight pain or discomfort

I have moderate pain or discomfort

I have severe pain or discomfort

I have extreme pain or discomfort

Anxiety / Depression

I am not anxious or depressed

I am slightly anxious or depressed

I am moderately anxious or depressed

I am severely anxious or depressed

I am extremely anxious or depressed

Overall Health Rating

We would like to know how good or bad your health is TODAY. You will see a scale numbered from 0 to 100. 100 means the best health you can imagine. 0 means the worst health you can imagine. Please indicate on the scale how your health is TODAY.

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Patient Watch Form - 1/30/2026