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Bill of Rights
Centers
Miami
Madrid
London
Physicians
Fernando J. Bianco, MD
Mark Emberton, MD
Edward L. Gheiler
Juan I. Martinez-Salamanca, MD
Ariel M. Kaufman, MD
Inventories
Health Inventories
QOL
SHIM
IPSS
IIEF-15
EQ5
WPAI
BAPS
RSES
COPS-P
Clinical Trials
Publications
Contact Us
Urological Research Network
URN
home
Bill of Rights
Centers
Miami
Madrid
London
Physicians
Fernando J. Bianco, MD
Mark Emberton, MD
Edward L. Gheiler
Juan I. Martinez-Salamanca, MD
Ariel M. Kaufman, MD
Inventories
Health Inventories
QOL
SHIM
IPSS
IIEF-15
EQ5
WPAI
BAPS
RSES
COPS-P
Clinical Trials
Publications
Contact Us
Inventories
Health Inventories
QOL
SHIM
IPSS
IIEF-15
EQ5
WPAI
BAPS
RSES
COPS-P
EuroQol Group EQ-5D
EQ-5D-5L
Under each heading, please check the ONE box that
best describes
your health TODAY
SubID
*
Name
First Name
Last Name
Date of Birth
MM
DD
YYYY
Email
*
MOBILITY
*
Please check the ONE LINE that best describes your health TODAY
1- I have no problems walking
2- I have slight problems walking
3- I have moderate problems walking
4- I have severe problems walking
5- I am unable to walk
SELF-CARE
*
Please check the ONE LINE that best describes your health TODAY
1- I have no problems washing or dressing myself
2- I have slight problems washing or dressing myself
3- I have moderate problems washing or dressing myself
4- I have severe problems washing or dressing myself
5- I am unable to wash or dress myself
USUAL ACTIVITIES
*
(e.g. work, study, housework, family or leisure activities) - Please check the ONE LINE that best describes your health TODAY
1- I have no problems doing my usual activities
2- I have slight problems doing my usual activities
3- I have moderate problems doing my usual activities
4- I have severe problems doing my usual activities
5- I am unable to do my usual activities
PAIN / DISCOMFORT
*
Please check the ONE LINE that best describes your health TODAY
1- I have no pain or discomfort
2- I have slight pain or discomfort
3- I have moderate pain or discomfort
4- I have severe pain or discomfort
5- I have extreme pain or discomfort
ANXIETY / DEPRESSION
*
Please check the ONE LINE that best describes your health TODAY
1- I am not anxious or depressed
2- I am slightly anxious or depressed
3- I am moderately anxious or depressed
4- I am severely anxious or depressed
5- I am extremely anxious or depressed
YOUR HEALTH TODAY
*
We would like to know how good or bad your health is TODAY This scale is numbered from 0 to 100. 100 means the best health you can imagine. 0 means the worst health you can imagine. Now, please write the number you marked on the scale in the box below.
Thank you!
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