52 PROMIS 29 Participant

Attachment 52
PROMIS 29 - Participant

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Expiration Date: XX/XX/XXXX

PROMIS 29 – Participant Adults and Children 13-17
Estimated time burden: 2 minutes
On the next screens we will ask questions about how you feel and any difficulties you have
doing a variety of activities. Read each question carefully and answer as well as you can.
After you make your choice, the computer will automatically go on to the net question. If you
want to change your answer, click on the GO BACK button to return to the previous question
and then choose a different answer.
[PFA11]
Are you able to do chores such as vacuuming or yard work? 1
Without any difficulty
With a little difficulty
With some difficulty
With much difficulty
Unable to do

[PFA21]
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

[PFA23]
Are you able to go for a walk of at least 15 minutes?
Without any difficulty
With a little difficulty

Public reporting burden for this collection of information is estimated to average 2 1/2 hours per response, including
the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not
required to respond to, a collection of information unless it displays a currently valid OMB control number. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions
for reducing this burden to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD
20892-7974, ATTN: PRA (0925-xxxx*) EXP: (xx/xxxx). Do not return the completed form to this address.

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With some difficulty
With much difficulty
Unable to do

[PFA53]
Are you able to run errands and shop?
Without any difficulty
With a little difficulty
With some difficulty
With much difficulty
Unable to do

[EDANX01]
In the past 7 days…I felt fearful.
Never
Rarely
Sometimes
Often
Always

[EDANX40]
In the past 7 days…I found it hard to focus on anything other than my anxiety.
Never
Rarely
Sometimes
Often
Always

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[EDANX41]
In the past 7 days…my worries overwhelmed me.
Never
Rarely
Sometimes
Often
Always

[EDANX53]
In the past 7 days…I felt uneasy.
Never
Rarely
Sometimes
Often
Always

[EDDEP04]
In the past 7 days…I felt worthless.
Never
Rarely
Sometimes
Often
Always

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[EDDEP06]
In the past 7 days…I felt helpless.
Never
Rarely
Sometimes
Often
Always

[EDDEP29]
In the past 7 days…I felt depressed.
Never
Rarely
Sometimes
Often
Always

[EDDEP41]
In the past 7 days…I felt hopeless.
Never
Rarely
Sometimes
Often
Always

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[HI7]
During the past 7 days…I feel fatigued.
Not at all
A little bit
Somewhat
Quite a bit
Very much

[FATEXP40]
In the past 7 days…How fatigued were you on average?
Not at all
A little bit
Somewhat
Quite a bit
Very much

[FATEXP41]
In the past 7 days…How run-down did you feel on average?
Not at all
A little bit
Somewhat
Quite a bit
Very much

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[An3]
During the past 7 days…I have trouble starting things because I am tired.
Not at all
A little bit
Somewhat
Quite a bit
Very much

[Global07]
In the past 7 days…How would you rate your pain on average?
0 No pain
1
2
3
4
5
6
7
8
9
10 Worst imaginable pain

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[PAININ9]
In the past 7 days…How much did pain interfere with your day to day activities?
Not at all
A little bit
Somewhat
Quite a bit
Very much

[PAININ22]
In the past 7 days…How much did pain interfere with work around the home?
Not at all
A little bit
Somewhat
Quite a bit
Very much

[PAININ31]
In the past 7 days…How much did pain interfere with your ability to participate in social
activities?
Not at all
A little bit
Somewhat
Quite a bit
Very much

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[PAININ34]
In the past 7 days…How much did pain interfere with your household chores?
Not at all
A little bit
Somewhat
Quite a bit
Very much

[Sleep109]
In the past 7 days…My sleep quality was...
Very poor
Poor
Fair
Good
Very good

[Sleep116]
In the past 7 days…My sleep was refreshing.
Not at all
A little bit
Somewhat
Quite a bit
Very much

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[Sleep20]
In the past 7 days…I had a problem with my sleep.
Not at all
A little bit
Somewhat
Quite a bit
Very much

[Sleep44]
In the past 7 days…I had difficulty falling asleep.
Not at all
A little bit
Somewhat
Quite a bit
Very much

[SRPSAT07]
In the past 7 days…I am satisfied with how much work I can do (include work at home).
Not at all
A little bit
Somewhat
Quite a bit
Very much

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[SRPSAT24]
In the past 7 days…I am satisfied with my ability to work (include work at home).
Not at all
A little bit
Somewhat
Quite a bit
Very much

[SRPSAT47]
In the past 7 days…I am satisfied with my ability to do regular personal and household
responsibilities.
Not at all
A little bit
Somewhat
Quite a bit
Very much

[SRPSAT49]
In the past 7 days…I am satisfied with my ability to perform my daily routines.
Not at all
A little bit
Somewhat
Quite a bit
Very much