World Health Survey Template Page 6
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57.
2000. Health State Descriptions
Time Begin: __ __ : __ __
..
Overall Health
..
The first questions are about your overall health, including both your physical and your mental health.
.
Q2000 In general, how would you rate your health today?
1. Very good
2. Good
3. Moderate
4. Bad
5. Very Bad
Q2001 Overall in the last 30 days, how much difficulty did you have with work
1. None
2. Mild
3. Moderate
4. Severe
5. Extreme/
or household activities?
Cannot do
..
Now I would like to review different functions of your body. When answering these questions, I would like you to think about the last 30 days, taking both
good and bad days into account. When I ask about difficulty, I would like you to consider how much difficulty you have had, on an average, in the past 30
days, while doing the activity in the way that you usually do it. By difficulty I mean requiring increased effort, discomfort or pain, slowness or changes in the
way you do the activity. Please answer this question taking into account any assistance you have available. (Read and show scale to respondent).
Mobility
Q2010 Overall in the last 30 days, how much difficulty did you have with
1. None
2. Mild
3. Moderate
4. Severe
5. Extreme/
Cannot do
moving around?
Q2011 In the last 30 days, how much difficulty did you have in vigorous
1. None
2. Mild
3. Moderate
4. Severe
5. Extreme/
Cannot do
activities, such as running 3 km (or equivalent) or cycling?
.
Self Care
.
Q2020 Overall in the last 30 days, how much difficulty did you have with self-
1. None
2. Mild
3. Moderate
4. Severe
5. Extreme/
care, such as washing or dressing yourself?
Cannot do
Q2021 In the last 30 days, how much difficulty did you have in taking care of and
1. None
2. Mild
3. Moderate
4. Severe
5. Extreme/
maintaining your general appearance (e.g. grooming, looking neat and
Cannot do
tidy etc.)
.
Pain and Discomfort
.
Q2030 Overall in the last 30 days, how much of bodily aches or pains did you
1. None
2. Mild
3. Moderate
4. Severe
5. Extreme
have?
Q2031 In the last 30 days, how much bodily discomfort did you have?
1. None
2. Mild
3. Moderate
4. Severe
5. Extreme
.
.
Cognition
.
Q2050 Overall in the last 30 days, how much difficulty did you have with
1. None
2. Mild
3. Moderate
4. Severe
5. Extreme/
concentrating or remembering things?
Cannot do
WORLD HEALTH SURVEY - HEALTH STATE DESCRIPTIONS
2.1
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Parent category: Life