| RPT |
|EuroQol Group 5-Dimension 5-Level Health Questionnaire (EQ-5D-5L)
| Gender: <.Patient_Gender.>
|
| Health State = <*Answer_7771*>
| EQ VAS = <-EQ VAS->
|
|
|Questions and Answers:
|
| 1. MOBILITY
| <*Answer_9049*>
|
| 2. SELF-CARE
| <*Answer_9050*>
| 3. USUAL ACTIVITIES (e.g. work, study, housework, family or leisure
| activities)
| <*Answer_9051*>
| 4. PAIN / DISCOMFORT
| <*Answer_9052*>
| 5. ANXIETY / DEPRESSION
| <*Answer_9053*>
| 6. YOUR HEALTH TODAY
| Date Given: <.Date_Given.>
| <*Answer_9054*>
|
|Information contained in this note is based on a self-report assessment
|and is not sufficient to use alone for diagnostic purposes. Assessment
|results should be verified for accuracy and used in conjunction with
|other diagnostic activities.
| Clinician: <.Staff_Ordered_By.>
| Location: <.Location.>
|
| Veteran: <.Patient_Name_Last_First.>
| SSN: <.Patient_SSN.>
| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)
|
