PROMIS-29

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

Unique ID

Name(Required)

First Last

Date of Birth(Required)

Physical Function

Are you able to do chores such as vacuuming or yard work?(Required)

Are you able to go up and down stairs at a normal pace?(Required)

Are you able to go for a walk of at least 15 minutes?(Required)

Are you able to run errands and shop?(Required)

Anxiety

In the past 7 days…

I felt fearful(Required)

I found it hard to focus on anything other than my anxiety(Required)

My worries overwhelmed me(Required)

I felt uneasy(Required)

Depression

In the last 7 days…

I felt worthless(Required)

I felt helpless(Required)

I felt depressed(Required)

I felt hopeless(Required)

Fatigue

During the past 7 days…

I feel fatigued(Required)

I have trouble starting things because am tired(Required)

Fatigue

In the past 7 days…

How run-down did you feel on average?(Required)

How fatigued were you on average?(Required)

Sleep disturbance

In the past 7 days…

My sleep quality was(Required)

My sleep was refreshing(Required)

I had a problem with my sleep(Required)

I had difficulty falling asleep(Required)

Ability to Participate in Social Roles and Activities

I have trouble doing all of my regular leisure activities with others(Required)

I have trouble doing all of the family activities that I want to do(Required)

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

I have trouble doing all of the activities with friends that I want to do(Required)

Pain Interference

In the past 7 days…

How much did pain interfere with your day to day activities?(Required)

How much did pain interfere with work around the home?(Required)

How much did pain interfere with your ability to participate in social activities?(Required)

How much did pain interfere with your household chores?(Required)

Pain Intensity

In the past 7 days…

How would you rate your pain on average?(Required)

This field is for validation purposes and should be left unchanged.

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