Promis- Global Health Questionnaire
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Excellent
Very good
Good
Fair
Poor
In general, how would you rate your health?
In general, how would you rate your quality of life?
In general, how would you rate your physical health?
In general, how would you rate your mental health, including mood and your ability to think?
In general, how would you rate your satisfaction with your social activities and relationships?
In general, how well do you carry out your usual social activities and roles? This includes activities at home, work, community, and responsibilities as a parent, friend, spouse, employee, etc.
Completely
Mostly
Moderatey
A little
Not at all
To what extent are you able to carry out your everyday physical activities such as walking, climbing stairs, carrying groceries, or moving a chair?
In the last 7 days
Never
Rarely
Sometimes
Often
Always
How often have you been bothered by emotional problems such as feeling anxious, depressed or irritable?
In the last 7 days
None
Mild
Moderate
Severe
Very severe
How would you rate your fatigue on average?
1
2
3
4
5
6
7
8
9
10
How would you rate your pain on average?
Calculation
Submit
Should be Empty: