PROMIS 10

First Name *

Last Name *

DOB: *

Please respond to each item by marking one box per row.

ExcellentVery goodGoodFairPoor

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.)

CompletelyMostlyModeratelyA littleNot at all

To what extent are you able to carry out your everyday physical activities such as walking, climbing stairs, carrying groceries, or moving a chair?

In the past 7 days:

NeverRarelySometimesOftenAlways

Global Physical Health score

Global Mental Health score

Global Physical t-score look up table

Raw Summed Score	T-‐Score	SE*
4	16.2	4.8
5	19.9	4.7
6	23.5	4.5
7	26.7	4.3
8	29.6	4.2
9	32.4	4.2
10	34.9	4.1
11	37.4	4.1
12	39.8	4.1
13	42.3	4.2
14	44.9	4.3
15	47.7	4.4
16	50.8	4.6
17	54.1	4.7
18	57.7	4.9
19	61.9	5.2
20	67.7	5.9

Global Mental Health t-score look up table

Raw Summed Score	T-‐Score	SE*
4	21.2	4.6
5	25.1	4.1
6	28.4	3.9
7	31.3	3.7
8	33.8	3.7
9	36.3	3.7
10	38.8	3.6
11	41.1	3.6
12	43.5	3.6
13	45.8	3.6
14	48.3	3.7
15	50.8	3.7
16	53.3	3.7
17	56.0	3.8
18	59.0	3.9
19	62.5	4.2
20	67.6	5.3

T Score - Global Physical Health Score *Please enter the T score by looking it up in the table

T Score Global Mental Health Score *Please enter the T score by looking it up in the table

EQ5D