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Promis 29 V2.1 Test

PROMIS 29 V2.1

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PROMIS 29 V2.1
Form

Outstanding Tasks0

Complete Tasks Below
Click on the items below to complete.

Promis 29 V2.1 Test

PROMIS 29 V2.1

Form

PROMIS 29 V2.1
Form

PROMIS 29 V2.1


Please respond to each question or statement by marking one box per row.

Are you able to do chores such as vacuuming or yard work?*

Are you able to go up and down stairs at a normal pace?*

Are you able to go for a walk of at least 15 minutes?*

Are you able to run errands and shop?*

Without any difficulty
With a little difficulty
With some difficulty
With much difficulty
Unable to do
Are you able to do chores such as vacuuming or yard work?
Are you able to go up and down stairs at a normal pace?
Are you able to go for a walk of at least 15 minutes?
Are you able to run errands and shop?
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Please respond to each question or statement by marking one box per row.

I felt fearful..*

I found it hard to focus on anything other than my anxiety.*

My worries overwhelmed me.*

I felt uneasy.*

Never
Rarely
Sometimes
Often
Always
I felt fearful..
I found it hard to focus on anything other than my anxiety.
My worries overwhelmed me.
I felt uneasy.
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Please respond to each question or statement by marking one box per row.

I felt worthless.*

I felt helpless.*

I felt depressed.*

I felt hopeless.*

Never
Rarely
Sometimes
Often
Always
I felt worthless.
I felt helpless.
I felt depressed.
I felt hopeless.
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Please respond to each question or statement by marking one box per row.

I feel fatigued.*

I have trouble starting things because I am tired.*

How run-down did you feel on average?*

How fatigued were you on average?*

Not at all
A little bit
Somewhat
Quite a bit
Very much
I feel fatigued.
I have trouble starting things because I am tired.
How run-down did you feel on average?
How fatigued were you on average?
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Please respond to each question or statement by marking one box per row.

In the past 7 days my sleep quality was...*

Very Poor
Poor
Fair
Good
Very Good
In the past 7 days my sleep quality was...
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Please respond to each question or statement by marking one box per row.

In the past 7 days my sleep was refreshing...*

In the past 7 days I had a problem with my sleep...*

In the past 7 days I had difficulty falling asleep...*

Not at all
A little bit
Somewhat
Quite a lot
Very much
In the past 7 days my sleep was refreshing...
In the past 7 days I had a problem with my sleep...
In the past 7 days I had difficulty falling asleep...
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Please respond to each question or statement by marking one box per row.

I have trouble doing all of my regular leisure activities with others.*

I have trouble doing all of the family activities that I want to do.*

I have trouble doing all of my usual work (include work at home).*

I have trouble doing all of the activities with friends that I want to do.*

Never
Rarely
Sometimes
Usually
Always
I have trouble doing all of my regular leisure activities with others.
I have trouble doing all of the family activities that I want to do.
I have trouble doing all of my usual work (include work at home).
I have trouble doing all of the activities with friends that I want to do.
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Please respond to each question or statement by marking one box per row.

How much did pain interfere with your day to day activities?*

How much did pain interfere with work around the home?*

How much did pain interfere with your ability to participate in social activities?*

How much did pain interfere with your household chores?*

Not at all
A little bit
Somewhat
Quite a lot
Very much
How much did pain interfere with your day to day activities?
How much did pain interfere with work around the home?
How much did pain interfere with your ability to participate in social activities?
How much did pain interfere with your household chores?
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