49 Pediatric PROMIS Physical Function Upper Extremity

Attachment 49

PROMIS Pediatric Physical Function Upper Extremity

Context

In the past 7 days

In the past 7 days

In the past 7 days

In the past 7 days

In the past 7 days

In the past 7 days

In the past 7 days

In the past 7 days

Stem

Responses

I needed help with a bath.

4=Never
3=Almost Never
2=Sometimes
1=Often
0=Almost Always

I could put on my socks by myself.

4=With no trouble
3=With a little trouble
2=With some trouble
1=With a lot of trouble
0=Not able to do

I could put on my shoes by myself.

4=With no trouble
3=With a little trouble
2=With some trouble
1=With a lot of trouble
0=Not able to do

I could open a jar by myself.

4=With no trouble
3=With a little trouble
2=With some trouble
1=With a lot of trouble
0=Not able to do

I could write with a pen or pencil.

4=With no trouble
3=With a little trouble
2=With some trouble
1=With a lot of trouble
0=Not able to do

I could put toothpaste on my toothbrush by myself.

4=With no trouble
3=With a little trouble
2=With some trouble
1=With a lot of trouble
0=Not able to do

I could brush my teeth by myself.

4=With no trouble
3=With a little trouble
2=With some trouble
1=With a lot of trouble
0=Not able to do

I could lift a cup to drink.

4=With no trouble
3=With a little trouble
2=With some trouble
1=With a lot of trouble
0=Not able to do

In the past 7 days

In the past 7 days

In the past 7 days

In the past 7 days

In the past 7 days

In the past 7 days

In the past 7 days

In the past 7 days

I could zip up my clothes.

4=With no trouble
3=With a little trouble
2=With some trouble
1=With a lot of trouble
0=Not able to do

I could pull on and fasten my seatbelt.

4=With no trouble
3=With a little trouble
2=With some trouble
1=With a lot of trouble
0=Not able to do

I could open my clothing drawers.

4=With no trouble
3=With a little trouble
2=With some trouble
1=With a lot of trouble
0=Not able to do

I could use a key to unlock a door.

4=With no trouble
3=With a little trouble
2=With some trouble
1=With a lot of trouble
0=Not able to do

I could pour a drink from a full pitcher.

4=With no trouble
3=With a little trouble
2=With some trouble
1=With a lot of trouble
0=Not able to do

I could dial a phone.

4=With no trouble
3=With a little trouble
2=With some trouble
1=With a lot of trouble
0=Not able to do

I could pull open heavy doors.

4=With no trouble
3=With a little trouble
2=With some trouble
1=With a lot of trouble
0=Not able to do

I could open the rings in school binders.

4=With no trouble
3=With a little trouble
2=With some trouble
1=With a lot of trouble
0=Not able to do

In the past 7 days

In the past 7 days

In the past 7 days

In the past 7 days

In the past 7 days

In the past 7 days

In the past 7 days

In the past 7 days

I could cut paper with scissors.

4=With no trouble
3=With a little trouble
2=With some trouble
1=With a lot of trouble
0=Not able to do

I could dry my back with a towel.

4=With no trouble
3=With a little trouble
2=With some trouble
1=With a lot of trouble
0=Not able to do

I could wash my face with a cloth.

4=With no trouble
3=With a little trouble
2=With some trouble
1=With a lot of trouble
0=Not able to do

I used a pencil with a special grip to write.

4=Never
3=Almost Never
2=Sometimes
1=Often
0=Almost Always

I could move my hands or fingers.

4=With no trouble
3=With a little trouble
2=With some trouble
1=With a lot of trouble
0=Not able to do

I could tie shoelaces by myself.

4=With no trouble
3=With a little trouble
2=With some trouble
1=With a lot of trouble
0=Not able to do

I could put on my clothes by myself.

4=With no trouble
3=With a little trouble
2=With some trouble
1=With a lot of trouble
0=Not able to do

I could turn door handles by myself.

4=With no trouble
3=With a little trouble
2=With some trouble
1=With a lot of trouble
0=Not able to do

In the past 7 days

In the past 7 days

In the past 7 days

In the past 7 days

In the past 7 days

I could button my shirt or pants.

4=With no trouble
3=With a little trouble
2=With some trouble
1=With a lot of trouble
0=Not able to do

I could pull a shirt on over my head by myself.

4=With no trouble
3=With a little trouble
2=With some trouble
1=With a lot of trouble
0=Not able to do

I could use a mouse or touch pad for the computer.

4=With no trouble
3=With a little trouble
2=With some trouble
1=With a lot of trouble
0=Not able to do

I could hold a full cup.

4=With no trouble
3=With a little trouble
2=With some trouble
1=With a lot of trouble
0=Not able to do

I could hold an empty cup.

4=With no trouble
3=With a little trouble
2=With some trouble
1=With a lot of trouble
0=Not able to do