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.

The worst health you can imagine

100

The best health you can imagine

Patient Watch Form - 5/1/2026