############################################################# ## ## Form name : SIRIS_EQ5D5L_GDZH ## Form version : V1 ## ############################################################# Date : 28.6.2019 INTERVAL (Examination interval) Type : radiobutton Data type : integer Answers: 0 = preop 1 = postop ------------------------------------------------------------------------------------ REASON_NO_EQ5D5L (EQ-5D-5L can't be filled out, because:) Type : radiobutton Data type : integer Optional question Answers: 1 = patient unable to present 2 = patient refused follow-up 3 = change of treating physician 4 = patient cannot be located 5 = patient died 6 = other reason Rules: Include question rules: Value 6 (other reason) activates question(s) - OTHER_REASON_NO_EQ5D5L (Please specify other reason) Exclude question rules: Value 1 (patient unable to present) deactivates question(s) - ANXIETY_DEPRESSION (Anxiety / Depression) - BACK_PAIN (Your health today) - EDUCATION_LEVEL (Level of education) - HEALTH_SLID (General health) - IV_DATE_QUESTION (Filled in on) - IV_LOCATION_QUESTION (Please indicate the joint that is currently being treated) - JOINT_SATISFACTION (Joint-specific satisfaction) - MOBILITY (Mobility) - PAIN_DISCOMFORT (Pain / Discomfort) - PAIN_SCORE (How severe was your pain during the last week?) - PAIN_SLID (Joint-specific pain) - SCORE (Index value) - SCORE_EQ_HEALTHSTATE (Health state value) - SELF_CARE (Self-Care) - SURGERY_DATE (Surgery Date) - USUAL_ACTIVITIES (Usual Activities (e.g. work, study, housework, family or leisure activities)) Value 2 (patient refused follow-up) deactivates question(s) - ANXIETY_DEPRESSION (Anxiety / Depression) - BACK_PAIN (Your health today) - EDUCATION_LEVEL (Level of education) - HEALTH_SLID (General health) - IV_DATE_QUESTION (Filled in on) - IV_LOCATION_QUESTION (Please indicate the joint that is currently being treated) - JOINT_SATISFACTION (Joint-specific satisfaction) - MOBILITY (Mobility) - PAIN_DISCOMFORT (Pain / Discomfort) - PAIN_SCORE (How severe was your pain during the last week?) - PAIN_SLID (Joint-specific pain) - SCORE (Index value) - SCORE_EQ_HEALTHSTATE (Health state value) - SELF_CARE (Self-Care) - SURGERY_DATE (Surgery Date) - USUAL_ACTIVITIES (Usual Activities (e.g. work, study, housework, family or leisure activities)) Value 3 (change of treating physician) deactivates question(s) - ANXIETY_DEPRESSION (Anxiety / Depression) - BACK_PAIN (Your health today) - EDUCATION_LEVEL (Level of education) - HEALTH_SLID (General health) - IV_DATE_QUESTION (Filled in on) - IV_LOCATION_QUESTION (Please indicate the joint that is currently being treated) - JOINT_SATISFACTION (Joint-specific satisfaction) - MOBILITY (Mobility) - PAIN_DISCOMFORT (Pain / Discomfort) - PAIN_SCORE (How severe was your pain during the last week?) - PAIN_SLID (Joint-specific pain) - SCORE (Index value) - SCORE_EQ_HEALTHSTATE (Health state value) - SELF_CARE (Self-Care) - SURGERY_DATE (Surgery Date) - USUAL_ACTIVITIES (Usual Activities (e.g. work, study, housework, family or leisure activities)) Value 4 (patient cannot be located) deactivates question(s) - ANXIETY_DEPRESSION (Anxiety / Depression) - BACK_PAIN (Your health today) - EDUCATION_LEVEL (Level of education) - HEALTH_SLID (General health) - IV_DATE_QUESTION (Filled in on) - IV_LOCATION_QUESTION (Please indicate the joint that is currently being treated) - JOINT_SATISFACTION (Joint-specific satisfaction) - MOBILITY (Mobility) - PAIN_DISCOMFORT (Pain / Discomfort) - PAIN_SCORE (How severe was your pain during the last week?) - PAIN_SLID (Joint-specific pain) - SCORE (Index value) - SCORE_EQ_HEALTHSTATE (Health state value) - SELF_CARE (Self-Care) - SURGERY_DATE (Surgery Date) - USUAL_ACTIVITIES (Usual Activities (e.g. work, study, housework, family or leisure activities)) Value 5 (patient died) deactivates question(s) - ANXIETY_DEPRESSION (Anxiety / Depression) - BACK_PAIN (Your health today) - EDUCATION_LEVEL (Level of education) - HEALTH_SLID (General health) - IV_DATE_QUESTION (Filled in on) - IV_LOCATION_QUESTION (Please indicate the joint that is currently being treated) - JOINT_SATISFACTION (Joint-specific satisfaction) - MOBILITY (Mobility) - PAIN_DISCOMFORT (Pain / Discomfort) - PAIN_SCORE (How severe was your pain during the last week?) - PAIN_SLID (Joint-specific pain) - SCORE (Index value) - SCORE_EQ_HEALTHSTATE (Health state value) - SELF_CARE (Self-Care) - SURGERY_DATE (Surgery Date) - USUAL_ACTIVITIES (Usual Activities (e.g. work, study, housework, family or leisure activities)) Value 6 (other reason) deactivates question(s) - ANXIETY_DEPRESSION (Anxiety / Depression) - BACK_PAIN (Your health today) - EDUCATION_LEVEL (Level of education) - HEALTH_SLID (General health) - IV_DATE_QUESTION (Filled in on) - IV_LOCATION_QUESTION (Please indicate the joint that is currently being treated) - JOINT_SATISFACTION (Joint-specific satisfaction) - MOBILITY (Mobility) - PAIN_DISCOMFORT (Pain / Discomfort) - PAIN_SCORE (How severe was your pain during the last week?) - PAIN_SLID (Joint-specific pain) - SCORE (Index value) - SCORE_EQ_HEALTHSTATE (Health state value) - SELF_CARE (Self-Care) - SURGERY_DATE (Surgery Date) - USUAL_ACTIVITIES (Usual Activities (e.g. work, study, housework, family or leisure activities)) ------------------------------------------------------------------------------------ OTHER_REASON_NO_EQ5D5L (Please specify other reason) Type : string Depends on question(s): REASON_NO_EQ5D5L ------------------------------------------------------------------------------------ SURGERY_DATE (Surgery Date) Type : date Optional question Depends on question(s): REASON_NO_EQ5D5L ------------------------------------------------------------------------------------ IV_DATE_QUESTION (Filled in on) Type : date Depends on question(s): REASON_NO_EQ5D5L ------------------------------------------------------------------------------------ SCORE (Index value) Type : real Optional question Depends on question(s): REASON_NO_EQ5D5L ------------------------------------------------------------------------------------ SCORE_EQ_HEALTHSTATE (Health state value) Type : integer Optional question Depends on question(s): REASON_NO_EQ5D5L ------------------------------------------------------------------------------------ MOBILITY (Mobility) Type : radiobutton Data type : integer Answers: 1 = I have no problems in walking about 2 = I have slight problems in walking about 3 = I have moderate problems in walking about 4 = I have severe problems in walking about 5 = I am unable to walk about Depends on question(s): REASON_NO_EQ5D5L ------------------------------------------------------------------------------------ SELF_CARE (Self-Care) Type : radiobutton Data type : integer Answers: 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 Depends on question(s): REASON_NO_EQ5D5L ------------------------------------------------------------------------------------ USUAL_ACTIVITIES (Usual Activities (e.g. work, study, housework, family or leisure activities)) Type : radiobutton Data type : integer Answers: 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 Depends on question(s): REASON_NO_EQ5D5L ------------------------------------------------------------------------------------ PAIN_DISCOMFORT (Pain / Discomfort) Type : radiobutton Data type : integer Answers: 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 Depends on question(s): REASON_NO_EQ5D5L ------------------------------------------------------------------------------------ ANXIETY_DEPRESSION (Anxiety / Depression) Type : radiobutton Data type : integer Answers: 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 Depends on question(s): REASON_NO_EQ5D5L ------------------------------------------------------------------------------------ HEALTH_SLID (General health) Type : slider1 Data type : real Depends on question(s): REASON_NO_EQ5D5L ------------------------------------------------------------------------------------ BACK_PAIN (Your health today) Type : integer Min-Max answers : 0 to 100 Depends on question(s): REASON_NO_EQ5D5L ------------------------------------------------------------------------------------ IV_LOCATION_QUESTION (Please indicate the joint that is currently being treated) Type : radiobutton Data type : integer Answers: 1 = right hip 2 = left hip 3 = right knee 4 = left knee Depends on question(s): REASON_NO_EQ5D5L ------------------------------------------------------------------------------------ PAIN_SLID (Joint-specific pain) Type : slider1 Data type : real Depends on question(s): REASON_NO_EQ5D5L ------------------------------------------------------------------------------------ PAIN_SCORE (How severe was your pain during the last week?) Type : integer Min-Max answers : 0 to 10 Depends on question(s): REASON_NO_EQ5D5L ------------------------------------------------------------------------------------ JOINT_SATISFACTION (Joint-specific satisfaction) Type : radiobutton Data type : integer Answers: 1 = very satisfied 2 = somewhat satisfied 3 = neither satisfied nor dissatisfied 4 = somewhat dissatisfied 5 = very dissatisfied Depends on question(s): REASON_NO_EQ5D5L ------------------------------------------------------------------------------------ EDUCATION_LEVEL (Level of education) Type : radiobutton Data type : integer Answers: 1 = up to 9 years of education (compulsory education) 2 = 10 until 13 years (vocational education, secondary school, high school) 3 = more than 13 years of education (university, polytechnic, college of higher education, university of applied science) Depends on question(s): REASON_NO_EQ5D5L ------------------------------------------------------------------------------------