PROMIS@–29 Profile
Please respond to each question or statement by marking one box per row.
Physical Function
5. Without any difficulty
4. With a little difficulty
3. With some difficulty
2. With much difficulty
1. 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?
Anxiety (In the past 7 days…)
1. Never
2. Rarely
3. Sometimes
4. Often
5. Always
I felt fearful
I found it hard to focus on anything other than my anxiety
My worries overwhelmed me
I felt uneasy
Depression (In the past 7 days...)
1. Never
2. Rarely
3. Sometimes
4. Often
5. Always
I felt worthless
I felt helpless
I felt depressed
I felt hopeless
Fatigue (In the past 7 days...)
1. Not at all
2. A little bit
3. Somewhat
4. Quite a bit
5. 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?
Sleep Disturbance (In the past 7 days…)
5. Very poor
4. Poor
3. Fair
2. Good
1. Very good
My sleep quality was
In the past 7 days…
Not at all
A little bit
Somewhat
Quite a bit
Very much
My sleep was refreshing
I had a problem with my sleep
I had difficulty falling asleep
Ability to Participate in Social Roles and Activities
5. Never
4. Rarely
3. Sometimes
2. Often
1. 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
Pain Interference (In the past 7 days…)
1. Not at all
2. A little bit
3. Somewhat
4. Quite a bit
5. 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?
Pain Intensity (in the past 7 days…)
0
1
2
3
4
5
6
7
8
9
10
None
Worst pain imaginable
0 is None, 10 is Worst pain imaginable
Stress in Social/Family Situation
0
1
2
3
4
5
6
7
8
9
10
None
Need regular outside help
0 is None, 10 is Need regular outside help
Stress with Work
0
1
2
3
4
5
6
7
8
9
10
None
Need regular outside help
0 is None, 10 is Need regular outside help
Stress over Health
0
1
2
3
4
5
6
7
8
9
10
None
Need regular outside help
0 is None, 10 is Need regular outside help
Stress with Life in General
0
1
2
3
4
5
6
7
8
9
10
None
Need regular outside help
0 is None, 10 is Need regular outside help
Signature
Clear
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty:
Now create your own Jotform - It's free!
Create your own Jotform