Patient Health

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Under each heading, please tick the ONE box that best describes your health TODAY

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 moderate problems doing my usual activities

I have severe problems doing my usual activities

I am unable to do my usual activities

(e.g.) work, study, housework, family or leisure 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

Your Health Today

We would like to know how good or bad your health is TODAY. This scale is numbered from 0 to 100.
100 means the best health you can imagine.
0 means the worst health you can imagine.

Your Health Today

50

How’s your health today?

Your Health Today