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HOME
HIRE STAK TOOL
HEALTHCARE PROFESSIONALS
CASE STUDIES
SUBMIT DATA
ABOUT STAK
OUR STORY
STAK EXPLAINED
RESEARCH EVIDENCE
BLOG
TESTIMONIAL
CONTACT
FREE CONSULTATION
EQ-5D-5L Questionnaire
Under each heading, please tick the ONE box that best describes your health TODAY.
First Name*
Email*
Hospital Physio Email
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
We would like to know how good or bad your health is TODAY.
On a scale from 0 to 100 where 100 means the best health you can imagine and 0 is the worst health you can imagine, where do you feel like your health is?
PLEASE CLICK TO CONFIRM YOU ACCEPT THE
PRIVACY POLICY
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