EQ-5D-Y-5L health questionnaire (age 13-15)

Thank you for taking the time to complete this survey. It is part of the evaluation for the South East London Enhanced Sickle Cell Community Service and should take no more than five minutes to complete. You will be asked questions about your health today.

This survey covers five dimensions of health: mobility, looking after myself, doing usual activities, having pain or discomfort, and feeling worried, sad or unhappy. You will be asked to rate the severity of each dimension. Please answer honestly.

Confidentiality: All responses will be kept confidential and used solely for the stated purposes. All recorded responses and published data will be anonymized, and no personally identifiable information will be shared.

To learn more about this survey, visit the EQ-5D-Y-5L website. If you have any questions, please contact gst-tr.selsicklecommunity@nhs.net.

About you

Answers to these questions will only be used for demographic analysis and not to identify individuals. This information will be kept anonymous.

What is your date of birth?

What is your postcode?

Maximum 255 characters

0/255

What borough do you live in?

Bexley

Bromley

Greenwich

Lambeth

Lewisham

Southwark

Other

Unsure

What is your sex, as assigned at birth?

Male

Female

Prefer not to say

Which of the following best describes your ethnicity?

Select option

Appointment questions

The following questions are about the appointment you are attending TODAY.

Have you had any support from the sickle cell community team in the past 6 months?

* required

Yes

Unsure

Is this the first time you've filled out this survey?

* required

Yes

Unsure

Which team are you seeing at your appointment today?

* required

Nursing team

Multi-disciplinary team (MDT)

Welfare team

Psychology group session

I do not have an appointment today

If you are seeing the multi-disciplinary team (MDT), which member(s) of the team are you seeing today?

Dietitian

Pharmacist

Physiotherapist

Nurse

Health questions

Please select the ONE box that best describes your health TODAY.

10.

MOBILITY (walking about)

* required

I have no problems walking about

I have a little bit of a problem walking about

I have some problems walking about

I have a lot of problems walking about

I cannot walk about

11.

DOING USUAL ACTIVITIES (for example, going to school, hobbies, sports, playing, doing things with family or friends)

* required

I have no problems doing my usual activities

I have a little bit of a problem doing my usual activities

I have some problems doing my usual activities

I have a lot of problems doing my usual activities

I cannot do my usual activities

12.

LOOKING AFTER MYSELF

* required

I have no problems washing or dressing myself

I have slight problems washing or dressing myself

I have some problems washing or dressing myself

I have a lot of problems washing and dressing myself

I cannot wash or dress myself

13.

HAVING PAIN OR DISCOMFORT

* required

I have no pain or discomfort

I have a little bit of pain or discomfort

I have some pain or discomfort

I have a lot of pain or discomfort

I have extreme pain or discomfort

14.

FEELING WORRIED, SAD OR UNHAPPY

* required

I am not worried, sad or unhappy

I am a little bit worries, sad or unhappy

I am quite worries, sad or unhappy

I am really worried, sad or unhappy

I am extremely worried, sad or unhappy

15.

We would like to know how good or bad your health is TODAY.

Imagine a line numbered from 0 to 100.

0 = the worst health imaginable.

100 = the best health imaginable.

What number best represents your health TODAY? Type it into the text box below.

* required

Maximum 255 characters

0/255

16.

In the past month, how often have you missed school?

* required

None

1-2 days

3-5 days

6-10 days

More than 10 days

Not in education

17.

How confident do you feel in your ability to manage your sickle cell disease?

* required

Not at all confident

A little confident

Somewhat confident

Quite confident

Completely confident