| RPT |
|.|.|Patient Reported Outcome Measurement Information System (PROMIS) 29 Profile v1.0 |
Anxiety <*Answer_7772*> <*Answer_7779*>|
Depression <*Answer_7773*> <*Answer_7780*>|
Fatigue <*Answer_7774*> <*Answer_7781*>|
Sleep Disturbance <*Answer_7775*> <*Answer_7782*>|
Satisfaction with Social Role <*Answer_7776*> <*Answer_7783*>|
Pain Interference <*Answer_7777*> <*Answer_7784*>|
Pain Intensity <*Answer_8318*> N/A | |
| Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>|
Questions and Answers| |1. Physical Functioning: Are you able to do
chores such as vacuuming or yard work?|
<*Answer_8290*>| |
2. Physical Functioning: Are you able to go up and down stairs at a normal pace?|
<*Answer_8291*>| |
3. Physical Functioning: Are you able to go for a walk of at least 15 minutes?|
<*Answer_8292*>| |
4. Physical Functioning: Are you able to run errands and shop?|
<*Answer_8293*>| |
5. Anxiety: IN THE PAST 7 DAYS I felt fearful.|
Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>|
<*Answer_8294*>| |
6. Anxiety: IN THE PAST 7 DAYS I found it hard to focus on anything other than
my anxiety.|
<*Answer_8295*>| |
7. Anxiety: IN THE PAST 7 DAYS my worries overwhelmed me.|
<*Answer_8296*>| |
8. Anxiety: IN THE PAST 7 DAYS I felt uneasy.|
<*Answer_8297*>| |
9. Depression: IN THE PAST 7 DAYS I felt worthless.|
<*Answer_8298*>| |
SSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)
10. Depression: IN THE PAST 7 DAYS I felt helpless.|
<*Answer_8299*>| |
11. Depression: IN THE PAST 7 DAYS I felt depressed.|
<*Answer_8300*>| |
12. Depression: IN THE PAST 7 DAYS I felt hopeless.|
<*Answer_8301*>| |
13. Fatigue: DURING THE PAST 7 DAYS I feel fatigued.|
<*Answer_8302*>| |
14. Fatigue: DURING THE PAST 7 DAYS I have trouble STARTING things because I
am tired.|
| Gender: <.Patient_Gender.>| |
<*Answer_8303*>| |
15. Fatigue: IN THE PAST 7 DAYS - How run down did you feel on average?|
<*Answer_8304*>| |
16. Fatigue: IN THE PAST 7 DAYS - How fatigued were you on average?|
<*Answer_8305*>| |
17. Sleep Disturbance: IN THE PAST 7 DAYS my sleep quality was,|
<*Answer_8306*>| |
18. Sleep Disturbance: IN THE PAST 7 DAYS my sleep was refreshing,|
<*Answer_8307*>| |
19. Sleep Disturbance: IN THE PAST 7 DAYS I had a problem with sleep,|
<*Answer_8308*>| |
20. Sleep Disturbance: IN THE PAST 7 DAYS I had difficulty falling asleep,|
<*Answer_8309*>| |
21. Satisfaction with Social Role: IN THE PAST 7 DAYS I am satisfied with how
much work I can do (include work at home).|
<*Answer_8310*>| |
22. Satisfaction with Social Role: IN THE PAST 7 DAYS I am satisfied with my
ability to work (include work at home).|
<*Answer_8311*>| |
23. Satisfaction with Social Role: IN THE PAST 7 DAYS I am satisfied with my
ability to do regular personal and household responsibilities.|
<*Answer_8312*>| |
24. Satisfaction with Social Role: IN THE PAST 7 DAYS I am satisfied with my
ability to perform my daily routines.|
<*Answer_8313*>| |
25. Pain Interference: IN THE PAST 7 DAYS - How much did pain interfere in your day to day
activities?|
<*Answer_8314*>| |
26. Pain Interference: IN THE PAST 7 DAYS - How much did pain interfere
with your work around the house?|
TOTALS Raw Score T-Score| |
<*Answer_8315*>| |
27. Pain Interference: IN THE PAST 7 DAYS - How much did pain interfere with
your ability to participate in social activities?|
<*Answer_8316*>| |
28. Pain Interference: IN THE PAST 7 DAYS - How much did pain interfere with
your household chores?|
<*Answer_8317*>| |
29. Pain Intensity: How would you rate your pain on average?|
<*Answer_8318*>| |
Physical Function <*Answer_7771*> <*Answer_7778*>|
Information contained in this note is based on a self-report assessment
and is not sufficient to use alone for diagnostic purposes. Assessment
results should be verified for accuracy and used in conjunction with
other diagnostic activities.| |
2008-2016 PROMIS Health Organization and PROMIS Cooperative Group
$~
|
