Form Coding Instructions

Please respond to each question or statement by marking one box per row.

Source: HealthMeasures

61577-3 In general, how would you rate your physical health?

Observation ID in Form

Global03

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component
In general, would you say your health is
Property
Find
Time
Pt
System
^Patient
Scale
Ord
Method
PROMIS

Long Common Name

In general, would you say your health is [PROMIS]

Basic Attributes

Class
SURVEY.GNHLTH
Type
Surveys
First Released
Version 2.34
Last Updated
Version 2.83 (MAJ)
Change Reason
Release 2.71: METHOD_TYP: Removed Method because this concept is not specific to PROMIS; EXTERNAL_COPYRIGHT_LINK: Removed copyright because this concept is not specific to PROMIS; ANSWER_LIST_TYPE: Updated from Normative to Example for increased usability; AnswerListId: Updated for increased usability; CLASS: Updated as the concept is not unique to PROMIS;

Normative Answer List LL1012-5

AnswerCodeScoreAnswer ID
Excellent5LA9206-9
Very Good4LA13913-1
Good3LA8967-7
Fair2LA8968-5
Poor1LA8969-3

Member of these Panels

LOINCLong Common Name
99745-2Patient reported outcomes with LASIK - post-operative panel [Patient reported outcomes with LASIK]
99192-7Patient-reported outcomes with LASIK - pre-operative panel [Patient reported outcomes with LASIK]
75418-4PCORI patient-reported outcomes common measures - core and recommended [PROMIS]
94257-3PROMIS pediatric - global health 7 - version 1.0
106970-7PROMIS Scale v1.2 - Global Physical Health 4a
61576-5PROMIS short form - global - version 1.1
85524-7PROMIS short form - global - version 1.2
71934-4Veterans Rand health survey - 12 item (VR-12)
71933-6Veterans Rand health survey - 36 item (VR-36)

61582-3 To what extent are you able to carry out your everyday physical activities such as walking, climbing stairs, carrying groceries, or moving a chair?

Observation ID in Form

Global06

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component
To what extent are you able to carry out your everyday physical activities such as walking, climbing stairs, carrying groceries, or moving a chair
Property
Find
Time
Pt
System
^Patient
Scale
Ord
Method
PROMIS

Long Common Name

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

Basic Attributes

Class
SURVEY.PROMIS
Type
Surveys
First Released
Version 2.34
Last Updated
Version 2.83 (MIN)

Normative Answer List LL1013-3

AnswerCodeScoreAnswer ID
Completely5LA13937-0
Mostly4LA13938-8
Moderately3LA13939-6
A little2LA13940-4
Not at all1LA6568-5

Member of these Panels

LOINCLong Common Name
75418-4PCORI patient-reported outcomes common measures - core and recommended [PROMIS]
91722-9PROMIS item bank - physical function - version 2.0
106970-7PROMIS Scale v1.2 - Global Physical Health 4a
61576-5PROMIS short form - global - version 1.1
85524-7PROMIS short form - global - version 1.2

61584-9 In the past 7 days...How would you rate your fatigue on average?

Observation ID in Form

Global08r

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component
How would you rate your fatigue on average in past 7D
Property
Find
Time
7D
System
^Patient
Scale
Ord
Method
PROMIS

Long Common Name

How would you rate your fatigue on average in past 7 days [PROMIS]

Basic Attributes

Class
SURVEY.PROMIS
Type
Surveys
First Released
Version 2.34
Last Updated
Version 2.65 (MIN)

Normative Answer List LL4478-5

AnswerCodeScoreAnswer ID
None Copyright http://snomed.info/sct ID:260413007 None (qualifier value)5LA137-2
Mild4LA6752-5
Moderate Copyright http://snomed.info/sct ID:6736007 Moderate (severity modifier) (qualifier value)3LA6751-7
Severe2LA6750-9
Very severe1LA13958-6

Member of these Panels

LOINCLong Common Name
106970-7PROMIS Scale v1.2 - Global Physical Health 4a
61576-5PROMIS short form - global - version 1.1
85524-7PROMIS short form - global - version 1.2

61583-1 In the past 7 days…How would you rate your pain on average?

Observation ID in Form

Global07r

Fully-Specified Name

Component
How would you rate your pain on average in past 7D
Property
Find
Time
7D
System
^Patient
Scale
Ord
Method
PROMIS

Long Common Name

How would you rate your pain on average in past 7 days [PROMIS]

Basic Attributes

Class
SURVEY.PROMIS
Type
Surveys
First Released
Version 2.34
Last Updated
Version 2.83 (MIN)

Normative Answer List LL7589-6

AnswerCodeScoreAnswer ID
0 - No pain0LA19102-5
11LA6112-2
22LA34475-6
33LA6114-8
44LA6115-5
55LA10137-0
66LA10138-8
77LA10139-6
88LA10140-4
99LA10141-2
10 - worst imaginable pain10LA21948-7

Member of these Panels

LOINCLong Common Name
62337-1PROMIS item bank - 29 profile
62336-3PROMIS item bank - 43 profile
62338-9PROMIS item bank - 57 profile
106970-7PROMIS Scale v1.2 - Global Physical Health 4a
61576-5PROMIS short form - global - version 1.1
85524-7PROMIS short form - global - version 1.2

71971-6 PROMIS-10 Global Physical Health total score

Term Description

GPH = Global Physical Health. This score is calculated from question responses via coefficients. Valid range: 16.2 to 67.7.

Type of Entry

Question - computer calculates response [C]

Fully-Specified Name

Component
PROMIS-10 Global Physical Health score
Property
Tscore
Time
Pt
System
^Patient
Scale
Qn
Method
PROMIS

Long Common Name

PROMIS-10 Global Physical Health (GPH) score T-score

Basic Attributes

Class
SURVEY.GNHLTH
Type
Surveys
First Released
Version 2.40
Last Updated
Version 2.83 (MIN)
Order vs. Observation
Observation

Member of these Panels

LOINCLong Common Name
76464-7American Physical Therapy Association registry panel
106970-7PROMIS Scale v1.2 - Global Physical Health 4a
61576-5PROMIS short form - global - version 1.1
85524-7PROMIS short form - global - version 1.2

Example Units

UnitSource
{score}Example UCUM Units

71972-4 PROMIS-10 Global Physical Health raw score

Term Description

GPH = Global Physical Health. This score is obtained from answers to some questions. Valid range: integer 4 to 20.

Type of Entry

Question - computer calculates response [C]

Fully-Specified Name

Component
PROMIS-10 Global Physical Health score
Property
Score
Time
Pt
System
^Patient
Scale
Qn
Method
PROMIS

Long Common Name

PROMIS-10 Global Physical Health (GPH) score

Basic Attributes

Class
SURVEY.GNHLTH
Type
Surveys
First Released
Version 2.40
Last Updated
Version 2.67 (MIN)
Order vs. Observation
Observation

Member of these Panels

LOINCLong Common Name
106970-7PROMIS Scale v1.2 - Global Physical Health 4a
61576-5PROMIS short form - global - version 1.1
85524-7PROMIS short form - global - version 1.2

Example Units

UnitSource
{score}Example UCUM Units