|Patient Reported Outcome Measurement Information System (PROMIS) 29 Profile
| Gender: <.Patient_Gender.>
| |<*Answer_7771*>
| |
|Questions and Answers|
|Physical Function:
| 1. Are you able to do chores such as vacuuming or yard work?
| <*Answer_8583*>
| 2. Are you able to go up and down stairs at a normal pace?
| <*Answer_8584*>
| 3. Are you able to go for a walk of at least 15 minutes?
|PROMIS29 Profile v2.1
| <*Answer_8585*>
| 4. Are you able to run errands and shop?
| <*Answer_8586*>|
|Anxiety: In the past 7 days...
| 5. I felt fearful.
| <*Answer_8587*>
| 6. I found it hard to focus on anything other than my anxiety.
| <*Answer_8588*>
| 7. My worries overwhelmed me.
| <*Answer_8589*>
|
| 8. I felt uneasy.
| <*Answer_8590*>|
|Depression: In the past 7 days...
| 9. I felt worthless.
| <*Answer_8591*>
|10. I felt helpless.
| <*Answer_8592*>
|11. I felt depressed.
| <*Answer_8593*>
|12. I felt hopeless.
| Date Given: <.Date_Given.>
| <*Answer_8594*>|
|Fatigue: During the past 7 days...
|13. I feel fatigued.
| <*Answer_8595*>
|14. I have trouble STARTING things because I am tired.
| <*Answer_8596*>
|15. How run down did you feel on average?
| <*Answer_8597*>
|16. How fatigued were you on average?
| <*Answer_8598*>|
| Clinician: <.Staff_Ordered_By.>
|Sleep Disturbance: In the past 7 days...
|17. My sleep quality was
| <*Answer_8599*>
|18. My sleep was refreshing.
| <*Answer_8600*>
|19. I had a problem with my sleep.
| <*Answer_8601*>
|20. I had difficulty falling asleep.
| <*Answer_8602*>|
|Ability to Participate in Social Roles and Activities:
| Location: <.Location.>|
|21. I have trouble doing all of my regular leisure activities with others.
| <*Answer_8603*>
|22. I have trouble doing all of the family activities that I want to do.
| <*Answer_8604*>
|23. I have trouble doing all of my usual work (include work at home).
| <*Answer_8605*>
|24. I have trouble doing all of the activities with friends that I want to do.
| <*Answer_8606*>|
|Pain Interference: In the past 7 days...
|25. How much did pain interfere with your day to day activities?
| Veteran: <.Patient_Name_Last_First.>
| <*Answer_8607*>
|26. How much did pain interfere with work around the home?
| <*Answer_8608*>
|27. How much did pain interfere with your ability to participate in social
| activities?
| <*Answer_8609*>
|28. How much did pain interfere with your household chores?
| <*Answer_8610*>|
|Pain Intensity: In the past 7 days...
|29. How would you rate your pain on average?
| SSN: <.Patient_SSN.>
| <*Answer_8613*>
|
|
|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
| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)
|
