Title First Name Last Name Company Street Zip City Country Phone Email Work environment:–None–StudentAcademiaHospital / Clinical PracticeConsulting / Health ResearchGovernment / Non-Profit / HTA AgencyIndustry / Pharmaceutical / Medical DeviceHealth Care CommunicationsHealth InsurranceOtherImported data Title/Description: Objective: Design:–None–Intervention study (randomized or non-randomized trial)Observational study (including case-control, cohort and cross-sectional studies)Methodological studyRegistryRoutine data collectionPROMs – CanadaPROMs – SwedenOther Other design: Clinical area:–None–AcneAcupunctureAlcohol dependencyAngina (treatment options)AngioplastyAnorectal reconstructionAsthmaBlood transfusionBone marrow transplantBreast cancerBreast cancer screeningBronchitisCardiac surgeryCardiologyCardiovascular diseaseCataract surgeryChemotherapy (impact)Chronic fatigueChronic illnessCochlear implantationColles fractureColorectal carcinomaCongestive heart failureConservation work (benefits of)Cosmetic surgeryCystic fibrosisDementiaDetoxificationDiabetesDrug monitoring (nursing home residents)DyspepsiaDystoniaElderly (QOL)EndometriosisEnteral nutritionEpilepsyErectile dysfunctionFabry’s diseaseGastro-enteritisGeneral practiceGeriatricsGilles de la TouretteGraves eye diseaseGrowth HormoneHaemophiliaHip fracture/replacementHIV infectionHodgkin’s dis.HomeopathyHormone replacement therapyHospital waiting listsHysterectomyImperforate anusIncontinenceInguinal herniaIntensive careIntestinal failureIschaemic heart diseaseJoint replacementLeg ulcer clinicsLiver diseaseLiver transplantationLow back painLung cancerLung embolismLung transplantationLupusLymphoedemaLymphomaMagnetic Resonance ImagingMelanoma (stage III)MenorrhagiaMigraineMultiple SclerosisMyeloid LeukaemiaMyocardial infarctionNeonatal surgeryNeural tube defectsNeurosurgeryNon-Hodgkin’s diseaseNutritionObstructive sleep apnoeaOrthopaedic medicineOsteoarthritisOther / UnknownPainPancreatic cancerParenteral nutritionPeripheral arterial diseasePeripheral vascular diseasePhysiotherapyPicture archiving and Communication systems (PACS)Population health surveysPrimary careProstate cancerProstatic hypertrophyPsoriasisPsychiatric problems in GP practiceRedundancy (impact of)Rehabilitation (effects of)Renal (kidney stone disease)Renal disease (end-stage)Renal oncologyRespiratory illnessRheumatoid arthritisRhinitisRoad accidents (non-fatal)SchizophreniaSepsisSinusitisSmoking (impact of)StentStrokeTraumaTuberculosis (prevention in HIV)Turner’s syndromeUrologyVascular surgeryVenous leg ulcersVisual impairmentWeight loss (treatment for)Women’s surgery Other clinical area: Source of funding: Number of patients or respondents: Start date Contract: End date Contract: 1st Product of EQ-5D to use:–None–EQ-5D-3L PaperEQ-5D-3L PDAEQ-5D-3L TabletEQ-5D-3L WebEQ-5D-5L PaperEQ-5D-5L PDAEQ-5D-5L TabletEQ-5D-5L WebEQ-5D-Y Paper (Youth version 8-11 years)EQ-5D-Y Tablet (Youth version: 8-11 years)EQ-5D-Y PDA (Youth version: 8-11 years)EQ-5D-5L Proxy V1EQ-5D-5L Paper PsoriasisEQ-5D-5L REDCapEQ-5D-3L REDCap Other generic health measures: Other disease/condition health measures: Journal articles or published records: Published information EuroQol: Details available to colleagues:
