Under each heading, please tick one box that best describes your health today. For dimensions 1-5, if the value is missing, please enter 9. Ambiguous values (e.g. two boxes are ticked for a single dimension) should be treated as missing values
Mobility
1: I have no problems in walking about
2: I have slight problems in walking about
3: I have moderate problems in walking about
4: I have severe problems in walking about
5: I am unable to walk about
Self-care
1: I have no problems washing or dressing myself
2: I have slight problems washing or dressing myself
3: I have moderate problems washing or dressing myself
4: I have severe problems washing or dressing myself
5: I am unable to wash or dress myself
Usual activities (e.g. work, study, housework, family or leisure activities)
1: I have no problems doing my usual activities
2: I have slight problems doing my usual activities
3: I have moderate problems doing my usual activities
4: I have severe problems doing my usual activities
5: I am unable to do my usual activities
Pain/discomfort
1: I have no pain or discomfort
2: I have slight pain or discomfort
3: I have moderate pain or discomfort
4: I have severe pain or discomfort
5: I have extreme pain or discomfort
Anxiety/depression
1: I am not anxious or depressed
2: I am slightly anxious or depressed
3: I am moderately anxious or depressed
4: I am severely anxious or depressed
5: I am extremely anxious or depressed
How is your health today?
100 means the best health you can imagine
0 means the worst health you can imagine
Missing values should be coded as 999
If there is a discrepancy between where the respondent has placed the X and the number he/she has written in the box, administrators should use the number in the box