PROMIS 10 Quality of Life Survey
Quality of Life Survey
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Which Location are you serviced by? *
  1. In general, would you say your health is:   *
2. In general, would you say your quality of life is: *
3. In general, how would you rate your physical health? *
4. In general, how would you rate your mental health, including your mood and your ability to think? *
5. In general, how would you rate your satisfaction with your social activities and relationships? *
6. In general, please rate how well you carry out your usual social activities and roles. (This includes activities at home, at work and in your community, and responsibilities as a parent, child, spouse, employee, friend, etc.) *
7. To what extent are you able to carry out your everyday physical activities such as walking, climbing stairs, carrying groceries, or moving a chair?   *
8.  How often have you been bothered by emotional problems such as feeling anxious, depressed or irritable? *
9.  How would you rate your fatigue on average? *
10.  How would you rate your pain on average? *
No pain
Worst pain imaginable
Name *
Date of Birth *
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Date of Survey *
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