Physical and Mental Health PROMIS-29 * First Name Last Name Email * Physical Function: Are you able to do chores such as vacuuming or yard work? * without any difficulty with a little difficulty with some difficulty with much difficulty unable to do Physical Function: Are you able to go up and down stairs at a normal pace? * without any difficulty with a little difficulty with some difficulty with much difficulty unable to do Physical Function: Are you able to go for a walk for at least 15 minutes? * without any difficulty with a little difficulty with some difficulty with much difficulty unable to do Physical Function: Are you able to run errands and shop? * without any difficulty with a little difficulty with some difficulty with much difficulty unable to do Anxiety: In the past 7 days, I felt fearful . . . * never rarely sometimes often always Anxiety: In the past 7 days, I found it hard to focus on anything other than my anxiety . . . * never rarely sometimes often always Anxiety: In the past 7 days, my worries overwhelmed me . . . * never rarely sometimes often always Anxiety: In the past 7 days, I felt uneasy . . . * never rarely sometimes often always Depression: In the past 7 days, I felt worthless . . . * never rarely sometimes often always Depression: In the past 7 days, I felt helpless . . . * never rarely sometimes often always Depression: In the past 7 days, I felt depressed . . . * never rarely sometimes often always Fatigue: During the past 7 days, I felt fatigued . . . * not at all a little bit somewhat quite a bit very much Fatigue: During the past 7 days, I have had trouble initiating things because I am tired . . . * not at all a little bit somewhat quite a bit very much Fatigue: During the past 7 days, how run-down did you feel on average? * not at all a little bit somewhat quite a bit very much Fatigue: During the past 7 days, how fatigued were you on average? * not at all a little bit somewhat quite a bit very much Sleep Disturbance: In the past 7 days, my sleep quality was . . . * very poor poor fair good very good Sleep Disturbance: In the past 7 days, I had a problem with my sleep . . . * not at all a little bit somewhat quite a bit very much Ability to Participate in Social Roles and Activities: I had trouble doing all of my regular leisure activities with others . . . * never rarely sometimes usually always Ability to Participate in Social Roles and Activities: I have trouble doing all of the family activities that I want to do . . . * never rarely sometimes usually always Ability to Participate in Social Roles and Activities: I have trouble doing all of my usual work (include work at home) . . . * never rarely sometimes usually always Pain Interference: In the past 7 days, how much did pain interfere with your day-to-day activities? * not a lot a little bit somewhat quite a bit very much Pain Interference: In the past 7 days, how much did pain interfere with your work around the home? * not a lot a little bit somewhat quite a bit very much Pain Interference: In the past 7 days, how much did pain interfere with your ability to participate in social activities? * not a lot a little bit somewhat quite a bit very much Pain Interference: In the past 7 days, how much did pain interfere with your household chores? * not a lot a little bit somewhat quite a bit very much Pain Inte * not a lot a little bit somewhat quite a bit very much Your form has been submitted. I will be in touch with you.-Dr. Monya
