Mobility
I have no problems in walking aboutI have slight problems in walking aboutI have moderate problems in walking aboutI have severe problems in walking aboutI am unable to walk about

Self-Care
I have no problems washing or dressing myselfI have slight problems washing or dressing myselfI have moderate problems washing or dressing myselfI have severe problems washing or dressing myselfI am unable to wash or dress myself

Usual Activities
I have no problems doing my usual activitiesI have slight problems doing my usual activitiesI have moderate problems doing my usual activitiesI have severe problems doing my usual activitiesI am unable to do my usual activities

Pain / Discomfort
I have no pain or discomfortI have slight pain or discomfortI have moderate pain or discomfortI have severe pain or discomfortI have extreme pain or discomfort

Anxiety / Depression
I am not anxious or depressedI am slightly anxious or depressedI am moderately anxious or depressedI am severely anxious or depressedI 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?