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AHS EQ5D5L Health Questionnaire

AHS EQ5D5L Health Questionnaire

The link you have used to access this questionnaire is incorrect

Under each heading below, please select the ONE box or answer that best describes your health TODAY.

Are you still awaiting your surgery or investigation? Yes No UniqueCode

Has your health condition changed since being added to the waitlist? Much worse Worse Same Better Much better

MOBILITY I have no problems with walking around I have slight problems with walking around I have moderate problems with walking around I have severe problems with walking around I am unable to walk around PERSONAL CARE I have no problems with washing or dressing myself I have slight problems with washing or dressing myself I have moderate problems with washing or dressing myself I have severe problems with washing or dressing myself I am unable to wash or dress myself USUAL ACTIVITIES (e.g. work, study, housework, family or leisure 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 have severe problems doing 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 We would like to know how GOOD or BAD your health is TODAY
Where 100 means YOU ARE IN the best health you can imagine
and 0 means YOU ARE IN the worst health you can imagine
Please indicate how your health is TODAYWe would like to know how GOOD or BAD your health is TODAY

Last Updated: 08/03/2023

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Acknowledgement of Country

The Government of Western Australia acknowledges the traditional custodians throughout Western Australia and their continuing connection to the land, waters and community.

We pay our respects to all members of the Aboriginal communities and their cultures; and to Elders both past and present.

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