| Question | Response |
|---|---|
| Date Collected | |
| Perfomed | Yes No |
| Reason if not performed | |
| Mobility | I have no problems in walking about I have some problems in walking about I am confined to bed |
| 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 |
| Usual activities | 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 |
| Pain/Discomfort | I have no pain or discomfort I have moderate pain or discomfort I have extreme pain or discomfort |
| Anxiety/Depression | I am not anxious or depressed I am moderately anxious or depressed I am extremely anxious or depressed |
| Health state Visual Analog Score |