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Total # of Questions: 46

PROMIS cancer item bank - physical function - version 1.1 [89689-4]

Date Done

Time Done

Where Done

Comment

Name

Value

Units

Are you able to do chores such as vacuuming or yard work? [61597-1]

Are you able to push open a heavy door? [61598-9]

Are you able to exercise for an hour? [61599-7]

Are you able to carry a heavy object (over 10 pounds)? [61600-3]

Are you able to use a hammer to pound a nail? [61604-5]

Are you able to run or jog for two miles? [61605-2]

Are you able to go up and down stairs at a normal pace? [61607-8]

Are you able to climb several flights of stairs? [89682-9]

Are you able to do yard work like raking leaves, weeding, or pushing a lawn mower? [61610-2]

Are you able to do two hours of physical labor? [89683-7]

Are you able to run on uneven ground? [89684-5]

Are you able to pull heavy objects (10 pounds) towards yourself? [61612-8]

Are you able to get up off the floor from lying on your back without help? [61614-4]

Are you able to squat and get up? [61624-3]

Are you able to carry a laundry basket up a flight of stairs? [61625-0]

Are you able to run errands and shop? [61635-9]

Are you able to get in and out of a car? [61638-3]

Are you able to move a chair from one room to another? [61594-8]

Are you able to bend down and pick up clothing from the floor? [61595-5]

Are you able to climb up five steps? [61645-8]

Are you able to wash dishes, pots, and utensils by hand while standing at a sink? [61646-6]

Are you able to make a bed, including spreading and tucking in bed sheets? [61647-4]

Are you able to carry a shopping bag or briefcase? [61648-2]

Are you able to put on and take off your socks? [61652-4]

Are you able to run a short distance, such as to catch a bus? [61659-9]

Are you able to stand unsupported for 10 minutes? [61667-2]

Are you able to stand unsupported for 30 minutes? [61675-5]

Does your health now limit you in doing vigorous activities, such as running, lifting heavy objects, participating in strenuous sports? [61588-0]

Does your health now limit you in exercising regularly? [89681-1]

Does your health now limit you in bending, kneeling, or stooping? [61589-8]

Does your health now limit you in doing heavy work around the house like scrubbing floors, or lifting or moving heavy furniture? [61590-6]

Does your health now limit you in lifting or carrying groceries? [61591-4]

Does your health now limit you in bathing or dressing yourself? [61592-2]

Does your health now limit you in doing moderate work around the house like vacuuming, sweeping floors or carrying in groceries? [61639-1]

Does your health now limit you in putting a trash bag outside? [61640-9]

Does your health now limit you in taking care of your personal needs (dress, comb hair, toilet, eat, bathe)? [61676-3]

Does your health now limit you in doing moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf? [61677-1]

Does your health now limit you in doing housework or jobs around the house? [89685-2]

Does your health now limit you in doing recreational activities which require little exertion (e.g., card playing, knitting, etc.)? [89686-0]

Does your health now limit you in going for a short walk (less than 15 minutes)? [61679-7]

Does your health now limit you in hiking a couple of miles on uneven surfaces, including hills? [61641-7]

Does your health now limit you in participating in active sports such as swimming, tennis, or basketball? [61681-3]

Does your health now limit you in pursuing your hobbies or other leisure activities? [89687-8]

Does your health now limit you in traveling out of town for an overnight stay? [89688-6]

How much difficulty do you have doing your daily physical activities, because of your health? [61680-5]

PROMIS cancer physical function - version 1.1 T-score [89690-2]

Su	Mo	Tu	We	Th	Fr	Sa
		1	2	3	4	5
6	7	8	9	10	11	12
13	14	15	16	17	18	19
20	21	22	23	24	25	26
27	28	29	30

PLEASE WAIT