Promis- Global Health Questionnaire
Please complete this questionnaire for patients aged 0-12 years.
Patient Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Physical Function Mobility: In the last 7 days...
Rows
With no
trouble
With a
little
trouble
With
some
trouble
With
a lot of trouble
Not able
to do
I could do sports and exercise that other kids my age could do
I could get up from the floor
I could walk up stairs without holding on to anything
I have been physically able to do the activities I enjoy most
Anxiety: In the last 7 days...
Rows
Never
Almost never
Sometimes
Often
Almost always
I felt like something awful might happen..
I felt nervous
I felt worried
I worried when I was at home
Depressive Symptoms: In the last 7 days...
Rows
Never
Almost never
Sometimes
Often
Almost always
I felt everything in my life went wrong
I felt lonely
I felt sad
It was hard for me to have fun
Fatigue: In the last 7 days...
Rows
Never
Almost never
Sometimes
Often
Almost always
Being tired made it hard for me to keep up with my schoolwork
I got tired easily
I was too tired to do sports or exercise
I was too tired to enjoy the things I like to
do.
Pain Interference; In the last 7 days...
Rows
Never
Almost never
Sometimes
Often
Almost always
I had trouble sleeping when I had pain
It was hard for me to pay attention when I had pain
It was hard for me to run when I had
pain
It was hard for me to walk one block when I had pain
Pain Intensity; In the last 7 days...
Rows
1
2
3
4
5
6
7
8
9
10
How would you rate your pain on average?
Total
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IntellxxDNA Agreement
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Your DNA contains variants, or SNPs (single nucleotide polymorphisms), that may signal potential benefits as well as risks. Your DNA is not your destiny. In fact, understanding your genomic profile empowers you to make intelligent health and wellness choices now that may impact your future quality of life. Your doctor will review your genomic profile as one of several factors of consideration when making clinical decisions to help you achieve optimal health.
*
I understand
IntellxxDNA tests are not billable to insurance, are non-refundable, and cannot be transferred to another patient.
*
I understand
IntellxxDNA genomic reports are non-diagnostic.
*
I understand
IntellxxDNA is not a lab. Your specimen will be processed at third-party CLIA/CAP certified lab anonymously.
*
I understand
Patients cannot mail their specimen from the state of New York. Patients will be instructed to mail their specimen from outside of New York, for example, New Jersey, or Connecticut.
*
I understand
Due to the complexity of the tests performed in functional medicine, your doctor cannot answer questions about the results outside of a scheduled appointment.
*
I understand
By signing below, I acknowledge that my doctor or her staff has informed me of the out-of-pocket cost associated with the IntellxxDNA test. I confirm my understanding of this cost and consent to proceed with the test. I agree to the terms outlined above and authorize Healing Family Functional Medicine to use my credit card for payment on the IntellxxDNA provider portal. I understand that this payment is non-refundable and the transaction cannot be undone once processed.
*
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