| Name | Value |
|---|---|
| REPORT NUMBER | 190 |
| INSTRUMENT | PROMIS29 V2.1 |
| RPT | |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.>) |